Sugar Consumption at a Crossroads

Consumption at
a crossroads
September 2013
Research Institute
Thought leadership from Credit Suisse Research
and the world’s foremost experts
Sugar
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Introduction
The global obesity epidemic and related nutritional issues are
arguably this century’s primary social health concern. With
breakthroughs in the field of medicine, huge leaps in cancer
research and diseases such as smallpox and polio largely erad-
icated, people around the globe are, on average, living much
longer and healthier than they were decades ago. The focus
on well-being has shifted from disease to diet. The whole con-
cept of healthy living is a key pillar of our Credit Suisse Mega-
trends framework – themes we consider crucial in the evolu-
tion of the investment world. In this report, we specifically
explore the impact of “sugar and sweeteners” on our diets.
Although medical research is yet to prove conclusively that
sugar is in fact the leading cause of obesity, diabetes type II or
metabolic syndrome, we compare and contrast various studies
on its metabolic effects and nutritional impact. Alongside this,
we question some of the accepted wisdom as to what is per-
ceived as “good” and “bad” when it comes to sugar consump-
tion, namely as to whether a calorie consumed is the same
regardless of where it is derived from – sugar, fats, or protein –
and whether solid foods are “nutritionally different” to liquids.
Naturally, recent focus here – medical, media and regulatory
– has intensified on certain products, with soft drinks being the
common denominator for all three. Within the population, we
are already seeing a gradual reduction in the consumption of
sugar and a switch to an alternative “diet” or “low-fat” products,
particularly among the most highly educated. Demands for
regulation, or taxation to limit consumption, are growing. Yet
governments and health officials have so far taken a mixed
stance on the matter.
The potential for a surge in negative public opinion and the
looming threat of regulation and taxation are issues that the
food and beverage industry clearly must address, though the
extent to which they can do so without hurting their current
business models is up for question. A diversification into new
healthier products is gathering momentum. Change will bring
new investment opportunities with clear winners and losers.
What can we expect in the future? What should investors
focus on? Although a major consumer shift away from sugar
and high-fructose corn syrup may be some years away, and
outright taxation and regulation a delicate process, there is
now a trend developing. From the expansion of “high-intensity”
natural sweeteners to an increase in social responsibility mes-
sages from the beverage manufacturers, we see green shoots
for dietary changes and social health advancement. Ultimately,
we expect consumers, doctors, manufacturers and legislators
to all play a crucial role in changing the status quo for sugar.
Giles Keating, Head of Research for Private Banking and
Wealth Management
Stefano Natella, Co-Head of Global Securities Research
Contents
03 Introduction
04 Composition, consumption and
consequences
06 Medical research
16 The world sweetener market
18 Sugar
20 High-fructose corn syrup (HFCS)
21 High-intensity/artificial
sweeteners (HIS)
22 The consumers
26 Public policy initiatives
32 Corporates: Self-regulation
and opportunities
41 References
43 Bibliography
43 Imprint / Disclaimer
For more information, please contact:
Richard Kersley, Head of Global
Securities Products and Themes,
Credit Suisse Investment Banking,
[email protected]
Michael O’Sullivan, Head of Portfolio
Strategy & Thematic Research,
Credit Suisse Private Banking
michael.o’[email protected]
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There can be no doubt that the global
obesity epidemic has been at the cen-
ter of a major debate involving medical
research, healthcare professionals,
insurance companies and society at
large. More recently, research has
shown that a significant number of
chronic diseases, including coronary
heart diseases, metabolic syndrome,
and diabetes type II strongly correlate
with weight gain. The future costs of
dealing with all these diseases are put-
ting further pressure on the private and
public sectors’ finances alike.
While these diseases might result
from the combined effect of several
factors, recent focus – medical, media
and regulatory – has converged on the
role played by sugar consumption, with
soft drinks being the common denomi-
nator for all three. Opinions on the
effects of sugar range from those who
maintain that it is toxic to those who
say that it is a natural product and per-
fectly healthy at current levels of con-
sumption. While the parties on both
sides of the debate continue to dis-
agree on a number of important issues,
there are several areas where there are
few doubts.
1. The consumption of added sugar
(sugar not contained in natural products
like fruit or milk) or high-fructose corn
syrup (HFCS) has increased dramati-
cally over the last few decades. Added
sugar is now ubiquitous in processed
foods, both as a flavor enhancer and
preservative. The world daily average
consumption of sugar and HFCS
per person is now 70 grams (or 17
teaspoons) per day, up 46% since
30 years ago (when it was 48 grams
per day). This is the equivalent of
280 calories per day (four calories for
each gram of sugar). Yet, consumption
varies considerably from country to
country. At the top, we find the USA,
Brazil, Argentina, Australia and Mexico,
all at more than double the world aver-
age; ranging from 40 teaspoons for the
USA to 35 for Mexico. At the other
end, we find China with 7 teaspoons.
If you exclude children less than four
years old, you can add another
5%–10% to the numbers above.
2. While medical research is yet to
prove conclusively that sugar is the
leading cause of obesity, diabetes type
II and metabolic syndrome, the balance
of recent medical research studies are
coalescing around this conclusion.
Advances in understanding the nega-
tive effects of refined carbohydrates on
blood sugar regulation and cholesterol,
and the metabolic impacts of fructose,
are undermining the traditional view
that all calories are the same.

3. Genetic variations in insulin
response are an important factor and
allow some people to tolerate more
sugar than others. Even so, a scientific
statement issued by the American
Heart Association in 2009
1
recom-
mends that women take no more than
six teaspoons of added sugar a day
and men no more than nine. To put this
in context, a regular can of soda has
eight teaspoons of sugar, as does a
one cup serving of low-fat granola.
Based on the figures above, current
intake of added sugars is well above
these “recommended” levels in several
developed and developing countries.
4. Liquid and solid “sugar calories” are
handled differently by the body. The
energy that is obtained through bever-
correlation between obesity and soda
consumption across many populations
is convincing and is a particular risk
factor for childhood obesity. Mexico,
for example, ranks second in the world
in adult obesity, first in diabetes type II
– which is the leading cause of death
in the country – and fourth in infantile
obesity.
2

It also ranks second globally in
added sugar consumption per person
and second in the amount of soft drinks
consumed per person, with 95% of
soft drinks consumed (excluding water)
being full-calorie.
7. Regulators, governments and public
officials have done little so far to coun-
teract concerns, with very few notable
exceptions. Yet, we estimate that the
annual costs to the healthcare system
due to the global obesity epidemic are
in excess of USD 600 billion. But obe-
sity, as bad as it is, is not the most
worrisome issue.
Diabetes type II is now affecting
close to 370 million people worldwide,
with one in ten US adults affected by
it. The costs to the global healthcare
system are a staggering USD 470 bil-
lion according to the most recent esti-
mates from the International Diabetes
Federation, and represent over 10% of
all healthcare costs. In the USA alone,
the healthcare costs tied to diabetes
type II are estimated at USD 140 bil-
lion, compared to USD 90 billion for
tobacco-related healthcare costs. Even
more worrisome is that these numbers
are growing at a rate of 4% a year,
much faster than for obesity (1%–2%).
By 2020, the annual cost to the
healthcare system globally will reach
USD 700 billion and the people
affected will be close to 500 million.
Recent events would indicate that local
and national authorities around the
globe are beginning to take action,
with varying degrees of success. Inter-
ventions include anti-soda advertising
campaigns, tax levies, removal of
vending machines in schools and regu-
lation of portion size. However, as
Mayor Bloomberg discovered in New
York, when his attempt to limit cup
sizes was defeated in court, the com-
bined lobby of the sugar industry –
which is a huge employer and there-
fore has significant voting power and
that of the food and beverage manu-
facturers – makes things much more
difficult. After balancing arguments in
favor and against, we believe that taxa-
tion would be the best approach and
will provide the best outcome: reducing
consumption while helping the public
sector deal with the growing social and
medical costs.
8. Against growing negative public
opinion and the threat of regulation or
taxation, the food and beverage indus-
try is beginning to take steps toward
“self-regulation” and pro-active media
campaigns. The beverage industry has
also for some time recognized the
need to diversify into healthier prod-
ucts, including fruit juices, sports
drinks, bottled water and diet soda.
However, many of these products are
also coming under scrutiny; either as
sugar in a healthier guise (fruit juices)
or for the inferred disadvantages of
artificial sweeteners – particularly
Aspartame, whose application was
rejected six times by the Food and
Drug Administration (FDA).
9. In the process of self-regulating
and educating the public to take
advantage of healthier choices, the
beverage manufacturing industry has
one advantage: in most cases, it
already provides a healthier alternative
of the fully caloric version (which is not
the case for the tobacco and alcohol
industry. We believe the next step in
“self-regulation” will be to launch food
and beverages that use natural sweet-
eners with zero or minimal caloric con-
tent. The experiment of Coca-Cola
Life in Argentina (sweetened with half
Stevia and half sugar leading to a
50% reduction in calories) is an exam-
ple of what we expect to see over the
next few years.
10. Bringing all this together, we
believe that the “noise” on sugar and
its effects on our health will increase
rather than decrease. Even well
regarded and independent bodies like
the World Health Organization (WHO)
have to catch up. In all its reports on
diabetes, the WHO barely mentions
sugar as either a cause or as part of
the treatment (i.e. reducing sugar
intake). So the most likely outcome
over the next 5–10 years will be a sig-
nificant reduction in sugar consumption
and a marked increase in the role
played by high-intensity natural sweet-
eners in food and beverages. Soft
drink consumption might suffer some-
what in the short term, as it will take
some time for companies to success-
fully establish a new line of “healthier”
alternatives.
Composition, consumption
and consequences
1
Circulation, Journal of the American Heart Associa-
tion (August 2009) – http://circ.ahajournals.org/
content/120/11/1011.full.pdf
2
Data are based on measurements rather than
self-reported height and weight. OECD Health
Data 2011 – http://www.oecd.org/els/health-
systems/49105858.pdf
ages is interpreted and processed dif-
ferently by our body from energy that is
obtained through solid foods, even if
the overall quantity of calories con-
sumed is the same. Sugar by itself is a
poor source of calories as it provides
little nutritional value. Not surprisingly,
the public debate has centered on soft
drinks and the role they have played in
this issue.
5. The medical profession has many
times pointed to the link between sugar
and the diseases we mentioned above,
but definitive causality has been difficult
to prove, as experiments involve a large
number of individuals under direction to
follow a controlled diet for several
months or years. Yet, our proprietary
survey of general practitioners in the
USA, Europe and Asia shows that
close to 90% of participants support
these conclusions. In addition, there is
not a single study showing that added
sugar is good for you, which would be
expected if the impact of sugar or
HFCS was truly neutral.
6. Consumers are increasingly aware
of this debate. Within the population,
we are already seeing signs of reduc-
tion in the consumption of sugar, par-
ticularly among the most highly edu-
cated. Public opinion asking for some
regulation or taxation to limit consump-
tion is growing.
Sugar-sweetened beverages, which
are concentrated sources of sugar, are
becoming a main focus of consumers.
In the USA, 31% of sugar supply is
absorbed by the beverage industry.
As the sugar is in a solution, it is easily
and completely ingested, giving a large
injection of calories without the conse-
quential satiation of appetite. The
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There are also a number of factors where the debate
on medical research in this area is ongoing. Let us
start with the basics and focus on three important
facts that allow us to better understand some of the
consequences of “excess” sugar and HFCS intake:
obesity, diabetes type II and metabolic syndrome:
1. Fructose and glucose are essentially same
Fructose, also called fruit sugar, is one of three
monosaccharides (along with glucose and galac-
tose) that are absorbed during digestion. Fructose is
mainly ingested in one of two forms, either sucrose
(table sugar) or high-fructose corn syrup (also called
high-fructose maize syrup, glucose fructose syrup or
glucose/fructose). Sucrose consists of equal parts
fructose and glucose. High-fructose corn syrup
(HFCS), on the other hand, usually has 55% fruc-
Our review of the latest literature and our conver-
sations with experts in the field lead us to believe
that, in general, the biological impact of fructose is
essentially identical to that of glucose at the con-
centrations at which these nutrients are generally
consumed. The American Medical Association has
weighed in on the debate and concluded that it
does not believe there to be any difference
between HFCS and sucrose when it comes to
causing or aggravating conditions such as obesity
or diabetes type II.
2. Liquids and solids are handled differently
by the body
Much of the recent focus in the debate around
added sugars has focused on the sugars that come
from sweetened beverages. This is partially
tose and 42% glucose (in HFCS 55) or 42% fruc-
tose and 53% glucose (in HFCS 42). HFCS does
have some important commercial advantages over
table sugar, and is considerably cheaper, meaning it
is now regularly used as the main sweetener in bev-
erages. The temporal relationship between an
increase in HFCS consumption (especially in sweet-
ened beverages) and the increase in obesity has
also elevated the focus on the potentially unique role
that fructose may play in weight gain.
There have been a number of studies looking
for differences in how the body metabolizes fruc-
tose compared to glucose. Unfortunately, many
have been very short-term or carried out at levels
much higher than the concentrations at which
either nutrient is typically ingested. In addition, it is
rare for either substance to be consumed in isola-
tion in the typical human diet.
Medical
research
Medical research has made significant
progress, particularly in understanding the
way we process calories. Causality linking
excess sugar consumption to obesity,
diabetes type II and metabolic syndrome
is difficult to prove; but for the doctors
we surveyed the link is very strong.
Figure 1
Major sources of added sugar in the American diet
Source: Johnson et al, Circulation, 2009: 120:1011-1020. Food groups that contribute more than 5% of the
added sugars to the American diet are listed in decreasing order.
Food categories Contribution to added sugar intake
(% of total added sugar consumed)
Regular soft drinks 33.0
Sugars and candy 16.1
Cakes, cookies, pies 12.9
Fruit drinks (fruitades and fruit punch) 9.7
Dairy desserts and milk products (ice cream sweetened yogurt, 8.6
and sweetened milk)
Other grains (cinnamon toast and honey-nut waffles) 5.8
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because soft drinks and other sugar-sweetened
beverages are now the primary source of added
sugar in the typical American diet (Figure 1).
In addition, there is now compelling evidence
that supports the notion that energy obtained
through beverages is interpreted and processed
differently from energy obtained through solid
foods, even if the overall quantity of energy con-
sumed is the same. This was first shown by Flood-
Obbagy and Rolls
1
, who showed that there was no
impact on the amount of solid food that was con-
sumed during a meal if the subject was given noth-
ing, water or a soft drink in advance of the meal.
Similarly, Mattes et al
2
demonstrated that ingest-
ing a beverage did not impact the amount of calo-
ries that were ingested during a subsequent meal or
in the 24-hour period after the beverage was con-
sumed. When a solid food was given, however, the
number of calories that were ingested in the follow-
from sweetened beverages are also easier to iden-
tify and isolate, and potentially regulate, restrict or
tax as opposed to sugars that are almost ubiquitous
in all solid foods.
3. The response to sugar intake is individual
A final factor of no debate is that there is clearly a
genetic component to the development of obesity.
At a population level, one widely cited hypothesis
is that of the “thrifty genotype”, as coined by
geneticist James Neel
3
. This essentially argues
that the human genes selected over time were
those that helped humans survive challenging
times where there were frequent famines. The
environment that many of us now live in has plen-
tiful amounts of food available year round, but the
genes may still be focused on conserving energy
whenever possible and, in that way, can lead to
1
Flood-Obbagy and Rolls. “The effect of fruit in different forms
on energy intake and satiety at a meal” - Am Diet Assoc.
2009;109: 430–437. (2009)
2
Richard D. Mattes, PhD, MPH, RD; Wayne W. Campbell.
“Effects of Food Form and Timing of Ingestion on Appetite” –
Am Diet Assoc. 2009;109:430–437 (2009)
3
Neel, James. ‘Diabetes Mellitus: “A ‘Thrifty’ Genotype Rendered
Detrimental by ‘Progress’?”– Am J Hum Genet. (December 1962)
4
Johnson, Rachel., et al. “Dietary Sugars Intake and Cardiovascular
Health” – Circulation 2009, 120:1011–1020 (August 2009)
5
Qi, Q., et Al. “Sugar-Sweetened Beverages and Genetic
Risk of Obesity” – New England Journal of Medicine 367:
15: 1387–1396 (September 2012)
ing meal and in the following 24-hour period was
reduced, suggesting the solid calories that had
been ingested were processed in a different way,
either in the intestine or in the central nervous sys-
tem, so that the body appropriately adjusted its sub-
sequent calorie intake. With calories from liquids,
however, the body does not seem to compensate
and the calories are “added on” to what the person
would have ingested anyway. This is not surprising
as high-caloric drinks became available only in the
late 1830s with the introduction of carbonated lem-
onade in the United Kingdom.
The amount of added sugars that come from
sugar-sweetened drinks, along with the evidence
that these calories are processed in a different way
to calories from solid foods, has contributed to the
scrutiny that sugar-sweetened beverages are now
under for potentially contributing to the increase in
overweight and obese individuals. These sugars
excess energy reserves and, over time, weight
gain and obesity.
Richard Johnson and others
4
sustain that homo
sapiens experienced two important genetic muta-
tions that increased our ability to store fat in sea-
sons where food was plentiful: the lack of the uri-
case enzyme and lack of the ability to make vitamin
C. These mutations enhanced our ability to increase
fat in response to our original major food source,
fruit, and increased our chance to survive in periods
of famine.
Many studies have also been completed that
look for individual genetic variations between sub-
jects who are and are not obese to try and identify
possible genetic variations that could play a role in
how a person consumes and processes energy.
More than 40 different genetic variants have been
identified to date that have been linked in some way
to an added risk of weight gain and obesity. In total,
genetics are believed to contribute between 30%
and 70% of the risk to developing obesity, with
environmental factors driving the rest of the risk.
Interestingly, a recent publication by Qi et al in
the New England Journal of Medicine
5
again
shows that sugar-sweetened beverages may play
a particular role in the development of obesity. In
this study Qi examined 32 genetic loci that have
been found to be associated with body mass index
(BMI) in the past and the impact these genes had
on weight gain. Upon examining the intake of
sugar-sweetened beverages, it was found that
there was a stronger association between the
presence of these genes and changes in BMI in
people who had a higher intake of sugar-sweet-
ened beverages as opposed to those who had a
lower intake of these drinks. While more research
is needed in this area, Qi’s work suggests that any
impact that genetics may have on weight gain may
be more pronounced in people who consume
more sugar-sweetened beverages. Another pos-
sibility may be that people who have a stronger
genetic predisposition to obesity may be more
sensitive to any potential weight gain caused by
these drinks.
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5. Is there a “fat switch?”
The general view is still that obesity is due to peo-
ple ingesting more calories than they burn. More
provocative research led by Richard Johnson from
the University of Colorado
8
now suggests that it
may not be as simple as that. Johnson suggests
that weight gain may be driven by activation of a
“fat switch” that increases the rate of fat storage
and that can drive weight gain. The trigger of this
switch could be the ingestion of sugar (and in par-
ticular fructose), although carbohydrates may trig-
ger this switch as well.
This theory is based in part on some of the
genetic factors behind obesity that were discussed
earlier and the fact that certain genes may have
been naturally selected over time as genes that
were favorable to helping people survive periods of
famine. These genes act as a switch that is acti-
vated when the body ingests sugar or carbohydrates
and leads to the more rapid production of fat.
Johnson and colleagues argue that the body is
especially sensitive to fructose (as opposed to
other sugars and carbohydrates) and that the
ingestion of fructose may have a more pronounced
impact on the “fat switch” and the production of fat.
Our review of the literature leaves us intrigued by
the fat switch theory although we admit that as of
now the science and data are inconclusive.
6. The diabetes link
The suspicion that increased consumption of sugar
leads to diabetes has been highlighted by several
doctors since the 1800s. Sir Frederick Banting,
who received the Nobel Prize in 1922 for his dis-
covery of insulin, linked the sharp increase of dia-
betes in the USA, to the sharp increase in sugar
consumption. Haven Emerson, the Commissioner
of Health for New York City in 1924 wrote a paper
entitled “The Sweet Death” and he too linked the
consumption of sugar to the sharp increase in dia-
betes among the wealthier New Yorkers. While
causality on a scientific basis requires more than
suspicions, the amount of data linking the sugar
consumption and diabetes has grown exponentially.
The debate flared up again earlier this year fol-
lowing the publication of a study by Basu et al
9
that
examined the potential impact of sugar on causing
diabetes, independent of other factors, including
overweight and obesity. This group found that for
every 150 kcal/person/day increase in sugar avail-
ability there was a 1.1% increased prevalence of
tions. On the other hand, perhaps those who pos-
sess a genetic predisposition to developing these
conditions (or someone who is already overweight or
obese) should be further restricted from consuming
sugary foods or have to pay greater prices for these
foods. Obviously, individualized regulations or taxes
such as these would be difficult to implement, add-
ing uncertainty about how regulations and taxes
should be used against sugary foods in general.
4. The obesity link
Globally, 35% of adults are considered overweight
and 12% of all adults are obese
6
. The rates of obe-
sity increased from 5% for men and 8% for women
in 1980 to 10% of men and 14% of women in
2008. It is now estimated that
7
205 million men
and 297 million women over the age of 20 are
obese, or more than half a billion adults worldwide.
There are a number of major health implications
from the rise in the number of people who are over-
weight and/or obese in both the developed world
and emerging markets. The landmark Global Bur-
den of Disease report published at the end 2012
highlighted obesity as a more significant health cri-
sis globally than hunger and/or malnourishment
and as the leading global cause of disabilities. The
five primary conditions that are linked to increases
in body mass index are high blood pressure, high
cholesterol, coronary heart disease, stroke and dia-
betes type II. Beyond these major conditions, being
overweight and/or obese also increases the risk of
numerous other disorders including osteoarthritis,
gout, nonalcoholic fatty liver disease, gallstones
and cancer.
Along with the health implications of the increase
in the number of people who are overweight and/or
obese, there are also significant economic impacts.
The direct cost of managing obesity-related condi-
tions has been estimated to be around USD 190
billion in the USA alone. There are also indirect
costs related to issues such as increased absentee-
ism, increased disability and increased premature
mortality that have been estimated to add as much
as USD 66 billion in additional costs in the USA.
In parallel with the increase in obesity, there has
also been a dramatic rise in the total amount of
calories being consumed each day. The number of
calories needed for the average male according to
the UK NHS (National Health Service) is 2500,
though the US authorities recommend 2700. What
is generally agreed is that sugar should account for
no more than 10% of caloric intake.
Actual consumption is now significantly ahead of
this in virtually every market, peaking at 3700 per
head per day in the USA. The emerging markets
have generally low per capita consumptions and the
developed world generally higher.
So is it just sugar that has led to an obesity epi-
demic? No, but sugar has been a major contributor,
beyond the simple amount of calories it added to
our diet.
Figure 3
US calorie consumption growth over the 20th century
Source: USDA, Credit Suisse Research
1909 1917 1925 1933 1941 1949 1957 1965 1973 1981 1989 1997 2005
Balance better vs worse
US calories consumption/per day
4200
4000
3800
3600
3400
3200
3000
Figure 4
Per capita sugar consumption 1996–97 and 2010–11
Source: Sucden
60
50
40
30
20
10
North AmericaSouth America Europe Asia Africa Oceania
1996–1997 2010–2011
0
Annual kg per capita
0 10 20 30 40
Self-reported data Measured data
% of adult population
United States
Mexico
New Zealand
Chile
Australia
Canada
United Kingdom
Ireland
Luxembourg
Finland
Iceland
Russian Fed.
Hungary
Greece
South Africa
Estonia
Czech Republic
Slovak Republic
Slovenia
Spain
Portugal
Turkey
Germany
Brazil
Belgium
Israel
Denmark
Poland
Austria
Netherlands
France
Sweden
Italy
Norway
Switzerland
Japan
Korea
China
Indonesia
OECD
India
Figure 2
Prevalence of obesity among adults, 2009
Source: OECD Health Data 2011; national sources for non-OECD countries.
6
OECD Health Data 2011
7
World Health Organization, Obesity Health Observatory (http://
www.who.int/gho/ncd/risk_factors/obesity_text/en/)
8
Johnson, Rachel., et al. “Dietary Sugars Intake and Cardiovascular
Health” – Circulation 2009, 120:1011–1020 (August 2009)
9
Basu S, Yoffe P, Hills N, Lustig RH (2013): “The Relationship of
Sugar to Population-Level Diabetes Prevalence: An Econometric
Analysis of Repeated Cross-Sectional Data”; PLoS ONE 8(2):
e57873. doi:10.1371/journal.pone.0057873
The individualized response to sugar consumption
contributes significantly to the debate about how
much government or health authorities should tax or
restrict access to foods or drinks with added sugars.
One of the reasons that supporters cite the need for
these measures is the significant economic impact
that obesity and other medical conditions have on
society as a whole. It could be argued that a person
at lower risk for developing any complications from
ingesting sugar should be able to avoid any restric-
tions and avoid paying any taxes since it is less likely
that they will develop the associated medical condi-
diabetes, independent of a variety of dietary, social
and economic factors (Figure 6). As with any pop-
ulation-based analysis such as this one, there are
limitations in the strength of the conclusions that
can be made from the study. It does add one more
piece of possible evidence on the side of the argu-
ment that there is something specific to sugar that
drives the development of conditions such as dia-
betes, beyond just the calories sugar contains and
the weight gain and obesity that the added calories
may cause.
The Basu study did a commendable job of
attempting to control for other factors that may
contribute to weight gain and obesity. It is essen-
tially impossible for a study to completely isolate
sugar for a long enough period of time to allow for
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[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
fully convincing results to be generated either in
support of or against sugar. One point that we find
interesting, however, is that there are no studies
that have been published (to our knowledge) that
suggest sugar has a protective benefit, while there
are a number of studies (including the Basu study)
that at least partially implicate sugar. If sugar truly
has no specific impact on the body when consid-
ered in isolation from other factors, one would
assume that random chance would lead to some
studies showing sugar to be beneficial, while others
show harmful effects and others show no effects.
7. The metabolic syndrome link
While it does appear that fructose and glucose are
handled in an essentially equivalent manner in the
body, there may be some conditions in the body
where fructose may have a greater detrimental
impact than glucose. Two specific conditions that
have been highlighted in the literature where fruc-
their use or consumption of the substance, (3) use
the substance compulsively, and (4) continue to
use it despite the harm it is causing.
Sugar may not pose the clear addictive charac-
teristics of illicit drugs such as cocaine and heroin,
but to us it does meet the criteria for being a poten-
tially addictive substance. It is clear that a prefer-
ence for sweet taste is innate in many people, with
sweeteners increasing the pleasure that people
obtain out of eating. The consumption of sweet
tasting foods and drinks has been shown to trigger
the release of the chemical dopamine in the basal
ganglia portion of the brain, the same response
that the brain has to stimulation by sexual arousal,
narcotics and other pleasurable stimuli. Most peo-
ple can also attest, at least anecdotally, to people
developing cravings for and compulsively consum-
ing certain sweet foods and drinks, even when they
are not necessarily hungry or thirsty. In addition,
many (if not most) people who are overweight or
obese continue to eat sugary substances even if
they realize that it is contributing to their calorie
intake and weight gain.
The more formal scientific data supporting the
view that sugar is addictive is somewhat limited and
based mainly on animal studies. Studies on labora-
tory rats have shown that rats can develop cravings
for sugar water. They also binge on sugar water
and show signs of withdrawal when the sugar water
is withheld. Rats have also been shown to develop
a tolerance to sugary substances. Over time, rats
that have been fed a sugary diet have a reduction
in the number of dopamine receptors in their brain,
leading to them needing to ingest more sugar to
achieve the same amount of dopamine release and
pleasure response.
Studies of this sort are more difficult to conduct
in humans. However, studies using functional brain
imaging techniques such as functional magnetic
resonance imaging (MRI) scans and positron emis-
sion tomography (PET) scans have shown that
obese individuals tend to have fewer dopamine
receptors in their basal ganglia, suggesting that
they may also need to eat more sweet foods to
Figure 6
Increased sugar availability has been associated with
increased diabetes prevalence
Source: Basu et al, PLoS ONE 8(2): e57873.
10
5
-5
-200 -100 0 100 200 300
Change in sugar availability (kcal/person/day)
Change in diabetes prevalence (%)
0
Figure 7
Metabolic syndrome is made
up of a group of fve metabolic
risk factors
Source: National Heart, Lung, and Blood Institute
Figure 8
Withdrawal from caffeine can cause
symptoms similar to those seen with
other addictive drugs
Source: American Psychiatric Association
generate the same dopamine release and pleasure
response. What is sometimes left out of the sugar
discussion is the fact that caffeine is often in the
same food and beverages that have significant
amounts of added sugar. Energy drinks, carbonated
beverages and chocolates are just some of the
examples of substances that have caffeine included
with added sugars. Caffeine also does not pose the
same risk of addiction as some other drugs but it
does stimulate the central nervous system, leads to
positive feedback loops and can cause withdrawal
symptoms when it is discontinued (Figure 8). Given
that caffeine and sugar are often ingested together,
it is sometimes difficult to isolate the impact of one
substance as opposed to the other. Regardless, an
addiction, or at least a mild-to-moderate depen-
dence, does seem to occur in some people to one
or both substances, contributing to people ingesting
more of the substance than they know they should.
9. Is there a threshold sugar intake level we
have crossed?
Most of the focus around sugar intake has assumed
that there is a linear dose response to increased
sugar consumption. As the consumption of sugar
has increased (along with the consumption of other
calories) there has been an increase in various med-
ical conditions. However, newer data suggest that a
linear dose response may be too simplistic.
10 11

There may be a threshold level in the body below
which sugars are without harm. Should this be sup-
ported by additional studies, then it could impact
how future dietary guidelines are written. It may
also help explain why the prevalence of certain con-
ditions continues to rise even if the rate of con-
sumption of soft drinks and some other sugar-
sweetened beverages may have leveled off.
tose may play a particular role are metabolic syn-
drome and nonalcoholic fatty liver disease (NAFLD).
Some of the opinions connecting fructose in par-
ticular to metabolic syndrome and nonalcoholic fatty
liver disease are driven by the temporal association
between the rise in fructose consumption (as part of
sugar and as part of high-fructose corn syrup) and
the rise of these conditions, but there is some bio-
logical rationale behind these concerns as well.
The metabolic syndrome is a constellation of
five different risk factors, each leading to an
increased risk of heart disease, diabetes and
stroke (Figure 7). Various studies on small-size
test samples have shown that fructose consump-
tion, but not glucose consumption, can increase
visceral adipose tissue, increase triglyceride levels
and lower HDL cholesterol levels. Other studies
have shown that fructose consumption may
increase liver enzymes, suggesting potentially
altered hepatic function and a possible rationale
behind the development of NAFLD.
Unfortunately, most of these studies have been
relatively small studies of short duration so the data
are not conclusive one way or the other. In addition,
the fact that fructose is almost always ingested
with glucose may make it difficult to ever have con-
clusive evidence of the isolated impact that either
nutrient is having in the body.
There are a couple of questions still being
debated without full agreement, but that are key to
understanding the implications for consumer, sugar
companies, and food and beverage manufacturers.
8. Is sugar as addictive as caffeine?

Some of the most vocal critics of the sugar industry
have expressed concerns that not only is sugar
toxic, but it may contain some addictive properties
that lead people to desire more and more sugar
over time. Addiction is a powerful term and, from a
medical perspective, requires some specific criteria
to be met. Specifically, in order for someone to be
addicted to a substance, they must (1) have crav-
ings for the substance, (2) be unable to control
Symptoms of caffeine withdrawal
Headaches
Fatigue
Anxiety
Irritability
Depressed mood
Difficulty concentrating
Metabolic risk factors
Large waistline/abdominal obesity
High triglycerides
Low HDL (“good”) cholesterol
High blood pressure
High fasting blood sugar
Figure 5
Estimated prevalence and healthcare costs of adults with diabetes
Source: UnitedHealth Group Modeling, 2010 (http://www.unitedhealthgroup.com/hrm/unh_workingpaper5.pdf)
Prevalence in adult
population
Health costs attributable
to diabetes (in USD bn)
2007 2010
(estimate)
2020
(estimate)
2007 2010
(estimate)
2011–20
(projection)
People with prediabetes 26.3 % 28.4 % 36.8 % 27 34 585
People with undiagnosed diabetes 2.9 % 3.1 % 4.1 % 12 15 253
People with type I diabetes 0.2 % 0.2 % 0.2 % 4 5 73
People with type II diabetes 7.6 % 8.2 % 10.8 % 110 140 2,439
Total 37.0 % 39.9 % 51.9 % 153 194 3,351
10
Johnson, RK, et al. AHA Scientific Statement: Dietary
Sugars Intake and Cardiovascular Health. Circulation 2009;
120: 1011–1020.
11
Rennie KL, Livingstone BE. Associations between dietary
added sugar intake and micronutrient intake: a systematic review.
British Journal of Nutrition. 2007; 97: 832–841.
SUGAR_12 SUGAR_13
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Figure 9
Would you say sugar consumption is linked to the
development of…?
Source: Credit Suisse Equity Reserarch Nutrition Survey, 2013
Obesity Type II Diabetes Non-Alcoholic/
Fatty Liver
US
EU
Asia
Global
Yes/Definitely yes
98%
85%
74%
86%
US
EU
Asia
Global
96%
92%
86%
91%
US
EU
Asia
Global
78%
73%
70%
74%
Figure 10
Should the government and health offcials do more to
reduce consumption of sugar, and will they in your opinion?
Source: Credit Suisse Equity Research Nutrition Survey, 2013
While research has yet to prove direct causality
between excess sugar consumption and obesity,
diabetes type II or metabolic syndrome, the medical
profession is regularly confronting these issues in
their day-to-day practice. It is interesting to observe
what doctors think of these issues. With this in
mind, we conducted a proprietary survey of 152
doctors in the USA, Europe and Asia. The results
are quite startling.
While most doctors do not appear to have much
specialized knowledge or training about nutrition
(and more specifically sugar or HFCS), 82% of the
doctors in the USA and Europe think that sugar
calories are handled differently by the body, com-
pared to only 60% in Asia. On the question “is
sugar addictive,” 65% think this is the case. There
is more: 98% of the doctors in the USA think that
US 82% US 56%
EU 90% EU 52%
Asia 86% Asia 62%
Global 86% Global 57%
0% 20% 40% 60% 80% 100%
None Minimal Moderate Extensive
USA
Asia Pacific
Global average
Europe
Figure 11
How would you describe the extent of training/coursework
you received on nutrition during your medical training?
Source: Credit Suisse Equity Research Nutrition Survey, 2013
0% 20% 40% 60% 80% 100%
Definitely not Probably not Maybe Probably yes Definitely yes
USA
Asia Pacific
Global average
Europe
0% 20% 40% 60% 80% 100%
Definitely not Probably not Maybe Probably yes Definitely yes
USA
Asia Pacific
Global average
Europe
Figure 12
Do you believe there is a difference between how sucrose
and fructose are handled by the body?
Source: Credit Suisse Equity Research Nutrition Survey, 2013
Figure 13
Do you believe sugar is addictive?
Source: Credit Suisse Equity Research Nutrition Survey, 2013
increased sugar consumption is linked to the devel-
opment of obesity, compared to 85% in Europe
and 94% in Asia. The same question regarding dia-
betes type II shows that 96% of the doctors we
surveyed in the USA believe there is a link with
increased sugar consumption versus 92% in
Europe and 86% in Asia.
Finally, we asked the survey participants if they
thought that the government or health authorities
should be doing more to reduce sugar and HFCS
consumption. Eighty-two percent of the doctors
answered yes in the USA, 90% in Europe and
86% in Asia. It is also interesting to notice that
when we asked whether they believed the govern-
ment or the health authorities are likely to do more
to reduce the consumption of sugar and HFCS,
only 57% responded yes.
The medical profession
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The world
sweetener market
Sugar accounts for over 80% of the sweetener market. Growth
has been basically in line with global population growth (2%), but
“free market” prices have suffered from excess supply. Among
high-intensity sweeteners, the fastest-growing segment is natural
sweeteners, while artificial sweeteners are under increased
scrutiny due to potentially negative “health effects.”
Figure 14
Global sweetener market 2011
Source: ISO Estimates – Volumes
Figure 15
Growth rates 2005–11
Source: ISO estimates
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
HIS Sugar HFCS Natural
sweeteners
0.0%
We have probed into the latest medical research on
the effects of sugar and HFCS. In order to better
assess the potential implications of this research
for consumers and corporations, we need to ana-
lyze the main features of the global sweeteners
industry (sugar, HFCS and other sweeteners).
The global sweetener market is estimated to be
around 190 million tons of “white sugar equivalent,”
and is unsurprisingly dominated by sugar. Each of
the major groups (high-intensity/artificial sweeten-
ers, sugar, and high-fructose corn syrup) has been
growing at a similar rate of circa 2% per annum,
though the most recent numbers have natural high-
intensity sweeteners growing rather faster.
Sugar is one of the most important agricultural
commodities traded internationally. The annual value
of world trade exceeds USD 24 billion. However
most sugar (71%) is consumed in the country of ori-
gin, so the global trade (imports/exports) totals
around 60 million tons, and Brazil accounts for 25–30
million tons of this. As the world market is a smaller
market, it is thus rather more sensitive to changes in
production – particularly in Brazil – than might other-
wise be thought. This means that, although there are
several producers globally, the key is to understand
what is happening in Brazil in particular, and to a less
extent in India, Thailand and China.
The market for high-intensity sweeteners, both
natural and artificial, is completely open, but the
products are the most heavily regulated among
sweeteners. These regulations vary from country to
country. A high-intensity sweetener cleared in one
country may be banned in another. The artificial
sweetener industry’s profile on health is somewhat
colored and many still see some of these products in
a bad light. This is not the case for natural HIS, the
largest portion of which is made of polyols (sugar
alcohols)
Finally, the market for HFCS is similar in size to
that of HIS, but is concentrated in three major mar-
kets: USA, China and Japan. The principal require-
ment for HFCS to flourish is government support.
HFCS can only truly become established where it is
allowed and where there is enough supply of starch.
82%
Sugar
7 %
HFCS
1% natural
sweeteners
10 %
HIS
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35
30
25
5
20
10
15
Jan 05
Jul 05
Jan 06
Jul 06
Jan 07
Jul 07
Jan 08
Jul 08
Jan 09
Jul 09
Jan 10
Jul 10
Jan 11
Jul 11
Jan 12
Jul 12
Jan 13
Surplus (inverted, r.h.s.) World price c/lb
-10000
-5000
0
5000
15000
10000
20000 0
Supply/demand
Sugar comes in two forms: (1) cane sugar (75%–
80% of world supply, grown in tropical climates),
and beet sugar (20%–25%, grown in temperate
climates). Some countries are large enough to
grow both crops (e.g. China and the USA). The
world sugar market is around 165 million tons and
is growing relatively steadily by around 2% per
annum. Supply is more cyclical, however, and can
depend on crop yields/weather, and the willingness
of farmers to plant crops (dependent on price).
Beet is a perennial so farmers’ decisions can be
influenced by the price of other crops (notably
cereals). Cane takes 18 months to reach maturity
and can yield sugar for typically five years (though
this can vary), after which yields will drop.
Many countries have regimes that protect the
local production through various mechanisms
including support prices, import restrictions, pro-
duction quota, etc. Examples include the US Farm
Act, the European Union Sugar Regime, or the
Chinese government’s controls on imports. Put
simply, the complexity of the infrastructure sur-
rounding sugar is significant. Thus, the traded mar-
ket (or the “world market”) is only 55–60 million
tons, and is sometimes referred to as the residual
market (where the sugar that is not a part of the
special agreements is bought and sold). The larg-
est producer of sugar by some distance is Brazil
(22% of world production), followed by India
(15%), China (8%) and Thailand (6%). However,
India and China consume all they produce, so if we
look at the supply to the “world market” instead,
this is dominated by Brazil (supplies typically half
the “world market”) and Thailand (10%–15%).
Sugar prices
The “residual” nature of the world market has made
the “world price” very volatile and sensitive to move-
ments in global supply versus demand. It has gen-
erally been in surplus (see Figure 19), but can react
sharply when a deficit is recorded or expected,
much as it did happen in 2009–11.
Brazil’s cost of production is generally thought to
be USD 18 cents/lb. and, in the long term, this
should be the floor of the market. As we mentioned
earlier, most of the markets are protected/con-
trolled, which means the local price bears little sig-
nificance to the world price – and trades at a sig-
nificant premium (see Figure 20). These regimes
have been in place for many years and are designed
to protect the local farmers from the vagaries of the
world price and guarantee them an economic return.
Politics versus economics
Hence, the dynamics of sugar have two principal
drivers: (1) Economics: The economics of supply/
demand, that have weather, crop yields, supply and
demand at their core; and (2) Politics: The extensive
lobbying power of the sugar industry is legendary (it
is often referred to as the second most political
commodity in the world – after oil). The industry is a
huge employer across the globe (there are 15 mil-
lion cane growers in China, and 350,000 beet
growers in Europe). Politicians are very sensitive to
protecting these businesses, and tailor regimes to
do exactly that. Leaving politics aside, we could see
a slight rebound in sugar prices in 2013–14 due to
the combination of three main factors: (1) A poten-
tial reduction in yields in some areas, (2) The cur-
rent low sugar prices are encouraging some pro-
ducers to shift their land use to other crops (mainly
grains) given better profitability, and (3) The planting
mix should continue moving toward ethanol produc-
tion as a consequence of recent government incen-
tives (and these incentives should continue because
of trade deficits caused by gasoline imports). Our
long-term price assumption USD 20 cents/lb (from
2014–15 onwards) is based on the level needed to
remunerate the cost of capital for this type of proj-
ect in Brazil. On the other hand, demand could be
weaker and keep prices around the current level.
Consensus points to demand growing around 2%
per year, very much in line with the 2% increase
seen over the past ten years. However, as we will
see later, consumption in developing countries is
likely to grow at these rates or even slightly higher,
but developed markets could see much slower
growth as concerns about the “medical” effects of
sugar gain further momentum.
Sugar
12 Figure 16
Supply/demand of world sugar (’000 tons)
Source: FO Licht
200000
180000
140000
160000
120000
100000
80000
60000
40000
20000
1997 1999 2001 2003 2005 2007 2009 2011 2013
Production Consumption
0
Figure 17
World sugar production
Source: FO Licht
Figure 18
World sugar production less consumption (m tons)
Source: Credit Suisse based on Czarnikow data
30000
25000
20000
15000
10000
5000
Brazil Thailand Australia Guatemala India
0
Figure 19
World price of sugar, versus world surplus/defcit
Source: Based on Chicago price for sugar and F O Licht supply/demand data
USD per lb 1.40
1.00
1.20
0.80
0.60
0.40
0.20
J
a
p
a
n
D
e
n
m
a
r
k
F
r
a
n
c
e
G
e
r
m
a
n
y
S
w
e
e
d
e
n
U
K
M
e
x
ic
o
C
a
n
a
d
a
A
u
s
t
r
a
lia
It
a
ly
S
p
a
in
U
S
A
B
r
a
z
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in
a
R
u
s
s
ia
In
d
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0.00
Figure 20
Average retail prices of sugar (USD/lb.)
Source: Company data, Credit Suisse estimates
6 % Thailand
8 % China
9 % EU
40 % Others
15 % India
22 % Brazil P
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12
For more details about the dynamics of the sugar market
please refer to “LatAm Sugar & Ethanol - More Challenges
Than Opportunities in Brazil’s Sugar & Ethanol Sector”,
Credit Suisse IB Equity Research, 29 July 2013.
SUGAR_19 SUGAR_18
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Figure 22
Global production of HFCS
Source: FO Licht
14000
12000
10000
8000
2000
4000
6000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
0
HFCS is obtained through an enzymatic process to
convert some of the glucose from corn syrup or
starch into fructose to deliver the desired sweet-
ness. Normally cheaper than cane or beet sugar, it is
sold in liquid form and has been widely adopted by
the food and beverage industry since 1975. Advo-
cates of sugar cane and beet sugar, contend that
HFCS is not a natural product and have been wag-
ing a legal battle in the USA to disallow the use of
the word “corn sugar” by HFCS producers. The FDA
has not allowed the use of this term and the debate
in then centered on whether HFCS is “natural.” This
is clearly a “marketing” battle. For the scope of our
study, sugar and HFCS are basically the same.
High-fructose corn syrup (HFCS)
High-intensity/artificial sweeteners (HIS)
Finding a high-intensity (or artificial) sweetener that
mimics sugar but without any health or taste issues
has long been the holy grail of the industry. There
have been a number of products over the year that
have significantly advanced the industry (Aspar-
tame, Sucralose, and possibly Stevia recently), but
thus far – despite the huge levels of R&D – no one
has managed to exactly mimic sugar.
The relative sweetness of these products by
weight to sugar varies significantly too, from 30
times to 1500 times, so that comparisons are best
made on a white sugar equivalent (WSE). The
global market is 18–19 million tons of WSE.
The relative prices of these sweeteners (again on
a WSE basis) are so far apart that the value share
of the market is materially different to the volume
share.
• Saccharin is the original artificial sweetener, and
dominates in volume terms, but sells at a fraction
of the price of sugar (less than USD 1 cent/lb. ver-
sus sugar over USD 25 cents). Often used as a
replacement for sugar on cost grounds in develop-
ing markets.
• Aspartame was first allowed in food and bever-
ages in the 1980s (launched by GD Searle), but
has always suffered from debates over its safety. It
is the principal sweetener in diet soft drinks And
sells at around USD 8 cents/lb.
As we mentioned before, the principal require-
ment for HFCS to flourish is government support.
With many (indeed most) sugar industries around
the world subject to some form of government
support and regime, HFCS can only truly get
established where it is allowed and where there is
enough supply of starch. 80% of the HFCS pro-
duction is found in the USA, Japan, China and
the EU. Global demand is growing very modestly
(up 1.3% per annum), reflecting current low
sugar prices (as seen in 2008/9). The current
spot price of bulk HFCS in the USA is now USD
29 cents/lb. versus 17 cents/lb. for sugar cane
and 26 cents/lb. for beet sugar.
• Acesulfame potassium (also known as Ace K);
launched by Hoechst in the 1980s. sells at around
USD 5 cents/lb., and is often combined with
Aspartame to form a cocktail of artificial sweeten-
ers in diet beverages.
• Sucralose was developed by Tate & Lyle in
1975 (marketed under the Splenda brand name)
and, finally gaining approval in 1998, it quickly
established itself as one of the pre-eminent artifi-
cial sweeteners (it is actually chlorinated sugar)
that, unlike other HIS, is able to be heated (thus
bringing in new industries where traditionally most
HIS were sold in beverages). T&L still dominates
supply with an 80%+ global share. Sucralose sells
at USD 20+ cents/lb.
• Stevia: Stevia is the only true natural product in
this list (polyols are too, but not the ones used
commercially). Prepared in different forms, Stevia
has been around for many decades, but recently
refining and improving its purity (notably by Pure-
Circle) has led to somewhat of a renaissance of the
product, which has helped it to gain significant
tranches of market share notably in the US table
top market.
• Other: There is a lot of research going into natu-
ral HIS. The most recent launches are derived from
the Monk fruit and from the Oubli fruit, but there is
more to come. This is a fast-growing area where
we expect the market to expand rapidly.
Figure 21
High-fructose corn syrup production
by country
Source: FO Licht
Figure 23
High-intensity sweetener volume
shares (WSE)
Source: ISO
Figure 24
HIS value shares (of global USD
1.2 billion market)
Source: ISO
3 % South Korea
4 % Turkey
5 % EU
6 % Japan
10 %
China
6 %
All others
66 %
North America
2 % Others 1 % Neotame
2 % Neotame 7 % AceK
8 % Natural HIS 4 % Stevia
7 % AceK
10 %
Sucralose
10 %
Cyclamates
24 %
Aspartame
41 %
Saccharin
26 %
Aspartame
34 %
Sucralose
12 %
Saccharin
12 %
Cyclamates
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The consumers
Added sugars now represent 17% of a normal US diet and we
estimate that 43% of added sugars come from sweetened beverages.
As public awareness of the potential negative effects of excess sugar
consumption has increased, consumers have been favoring “diet” soft
drinks over the “full-calorie” offerings. This is particularly true among
people with higher income and higher education.
Figure 25
US per capita daily calorie consumption in 2010
Source: United States Department of Agriculture Economic Research Service
While the largest contributor to the increase in cal-
ories has been the consumption of grains, fats and
oils, the consumption of sugar and sweeteners has
also increased, but at a somewhat slower rate than
overall calories.
Added sugar now represents 17% of a typical
US diet for a normal person, but if we evaluate the
diet as a whole, we estimate that sugars in their
different forms represent 38% of the typical intake.
Consumers “like” all sugar types, but we are now
beginning to see a shift in attitude when focusing
on added sugars and HFCS. Sugar in fruit for
example is still perceived as good, but added sugar
and HFCS may not be.
Is 17% a “healthy” level? According to the World
Health Organization, the recommended dietary
allowance is 2900 calories for men (aged 19–50)
and 2200 for women. In practice, many countries
are way above these guidelines. Furthermore the
World Health Organization recommends that added
sugars should contribute no more than 10% of the
total caloric intake. This would imply that the total
added sugar calories in the average diet should be
no more than 290 for men and 220 for women.
Many countries are clearly ahead of this level by a
significant margin.
It should be noted that added sugar is consumed
largely through processed foods and drinks, and
not as the basic product. Our estimates of the
caloric intake of sweeteners (HFCS and sugar) by
country is considerably higher than the recom-
mended 220–290 implied above.
Added sugar and HFCS are present in numer-
ous foods and beverages: from pasta sauces,
210 (8 %)
616 (23 %)
620 (24 %)
470 (18 %)
444 (17 %)
255 (10 %)
Added fats and oils and
dairy fats
Flour and cereal products
Meat, eggs, and nuts
Caloric sweeteners
Dairy
Fruit and vegetables P
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[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Here, the debate is centered around introducing
taxes on full-caloric drinks as a part of the new
budget, increased advertisement by food and bev-
erage manufacturers, attempting healthier posi-
tions of their brands, and increased “educational”
advertisement by health officials and consumer
organizations.
A few months ago, Coca-Cola launched a sim-
ple but subtle campaign promoting Coke as a
source of “needed” calories or – if you want to take
a different view – being completely transparent
about the caloric content of a coke bottle. The
response to the ad was swift. The Alianza para La
Salud Alimentaria (Alliance for Healthy Foods)
launched an ad showing the amount of sugar in a
bottle of soda (“would you drink twelve spoons of
sugar?”) and linking sugar in soft drinks to diabetes
(“the drink is sweet, but diabetes is not”). Another
association – El Poder de el Consumidor –
denounced the ad by Coke as misleading and dan-
gerous and demanded its withdrawal. A similar
advertisement in the UK, showing a bottle of Coke
with the message “139 happy calories to spend on
extra happy activities” had to be withdrawn after
the UK advertising supervisory body ruled that the
advertisement was misleading.
In this more contentious environment, Coca-
Cola Femsa, the largest coke distributor in Mexico
and Coke’s largest independent bottler globally,
has moved quickly to address directly health and
wellness issues. In its 2012 Sustainability Report,
the company mentions the “Let’s Play” program,
which was originally developed in Costa Rica, and
is now being rolled out in Argentina, Colombia,
Guatemala, Nicaragua and Panama. This is a
project of technical and didactic training, aimed at
school age children, focused mainly on issues of
physical activity and enhancing students’ psycho-
metric skills.
Another interesting fact that shows the growing
concern of consumers about full-calorie drinks
can be found in their willingness to support gov-
ernment regulation (including taxation) of sugar
and HFCS-sweetened beverages. In California,
68% of the people polled were in favor of taxing
full-calorie soft drinks if the revenues were used
to support school nutrition and physical activity
programs. In a 2010 poll run in the State of New
York, 58% of the people interviewed supported a
soft-drink tax, with a peak of 76% in New York
City. However, a 2012 pool of 592 people across
the USA revealed that 64% did not support a
20% tax on sodas.
Perhaps more interesting was that support for
the tax was highest among those underweight or
normal weight, those with the highest income
(greater than USD 65,000/annum) and those
with a higher education level. There was also a
significant racial divide, with 39% of non-Hispanic
whites supporting the tax versus 24% of black-
Americans. We were unable to find similar polls in
either Europe or Asia.
30%
20%
15%
25%
Diet soda consumption, as a % of total soda consumption 35%
10%
5%
0.4 0.5 0.6 0.8 0.9 0.7 1.0 1.1
0%
UN Education Index
Mexico
Argentina
USA
United Arab Emirates
R
2
0.4166
Chile
Belgium
Norway
Switzerland
Spain
Brazil
India
China
Malaysia
Russia
Japan
Hong Kong, China
Singapore
France
Italy
Poland
Peru
Slovakia
Bulgaria
South
Africa
Colombia
Venezuela
Czech Republic
Finland
Turkey
Hungary
Greece
Romania
South Korea
Ukraine Thailand
Philippines
Morocco
Egypt
Portugal
Indonesia
Denmark
Sweden
Netherlands
Germany
Canada
Israel
United Kingdom
Australia
Ireland
New Zealand
Saudi Arabia
Austria
Figure 30
Correlation between diet Coca-Cola drink consumption
and median income by region
Source: Nielsen, http://www.census.gov/people/
50%
40%
35%
45%
% diet Coca-Cola CSD vs Coca Cola CSD 55%
30%
25%
30 35 40 50 55 45 60 65
20%
Median income USD ’000
West North Central
Middle Atlantic
Mountain
West South Central
East South Central
South Atlantic
Pacific
East North Central
New England
50%
40%
35%
45%
% diet Coca-Cola CSD vs Coca Cola CSD 55%
30%
25%
15 20 25 35 30 40
20%
% of population with bachelor’s degree or more
West North Central
Middle Atlantic
Mountain
West South Central
East South Central
South Atlantic
Pacific
East North Central
New England
ketchup, pizza and cereals to a full array of bever-
ages. Note that 4.2 grams of sugar make up a
“teaspoon.” We are, therefore, referring to a large
number of teaspoons in most cases. Yet the main
focus for consumers regarding the potential health
issues tied to sugar has been on beverages and
particularly soft drinks. Why?
Sweetened beverages are now delivering an
increasingly greater percentage of the sugars that
are ingested in an average diet. Between 1955
and 2000, the consumption of soft drinks in
the USA increased from about ten gallons/person
to 54 gallons/person and then declined by around
20% until 2012, but with an equivalent increase
in the consumption of fruit juices and bottled
water. According to the USDA, the beverage
industry now accounts for 31% of total sweetener
deliveries and we estimate that 43% of added
sugars in a normal US diet come from sweetened
beverages.
A similar stabilizing trend can be seen in most
other developed markets, while consumption is still
on the rise in emerging markets. Why are we see-
ing stabilization or even a decline in some devel-
oped countries? Information is key. There is a
growing perception – not completely wrong as we
discussed – that caloric soft drinks have been
responsible for some of the health issues men-
tioned before. This perception is stronger among
people of higher education or higher income.
The consumers’ options
So what is likely to happen? Four main things:
1. As long-term trends in consumption are set by
those with higher education and higher income, we
expect the world to gradually move away from full-
calorie soft drinks to the diet versions of the same
drinks, when available.
2. In the USA and Europe, the diet or zero version
of the soft drink peaked around mid-2000 and
then declined gradually in line with the full-calorie
version. This reflects a growing concern with artifi-
cial sweeteners, particularly in Europe. We expect
this to be the case in other markets, but as we
discuss in the company section, we expect soft-
drink manufacturers to make attempts at substitut-
ing artificial sweeteners with natural ones, as the
taste profile of the latter improves. Consumers will
determine the success or failure of these newer
versions. The key is acceptance of new tastes or
delivering the same taste with fewer calories.
3. We expect consumer associations to be a lot
more proactive in raising potential health issues and
monitor advertisement and availability, particularly
for children. This applies to soft drinks sweetened
with sugar, HFCS or HIS.
4. Growing public support for regulation and poten-
tially taxation.
Mexico is a good example of what we can expect
on a more global scale in the next couple of years.
Figure 27
Sugar per serving in various foods and beverages
Source: SummerTomato.com
0 10 20 30 40 50 60 70
Sugar per serving (g)
Krispy Kreme original glazed doughnut
Luna Bar berry almond
Crunchy Nut/Frosties/Froot Loops cereal
Ben & Jerry's vanilla ice cream
Starbucks caffè latte grande
(16 oz/450 ml)
Godiva 2 truffles
Subway 6" sweet onion teriyaki chicken
Tropicana 100% orange juice
(8 oz/225 ml)
Yoplait original yogurt
Vitamin Water (20 oz/570 ml)
Coca-Cola (20 oz/570 ml)
Sprinkles Cupcake red velvet
California Pizza Kitchen Thai chicken salad
Odwalla Super Food (450 ml bottle)
Starbucks caffe vanilla frappuccino
(16 oz/450 ml)
percentage 37.0
35.0
36.0
34.0
33.0
32.0
31.0
30.0
29.0
28.0
1
9
8
4
1
9
8
5
1
9
8
6
1
9
8
7
1
9
8
8
1
9
8
9
1
9
9
0
1
9
9
1
1
9
9
2
1
9
9
3
1
9
9
4
1
9
9
5
1
9
9
6
1
9
9
7
1
9
9
8
1
9
9
9
2
0
1
1
2
0
1
0
2
0
0
9
2
0
0
8
2
0
0
7
2
0
0
6
2
0
0
5
2
0
0
4
2
0
0
3
2
0
0
2
2
0
0
1
2
0
0
0
27.0
Figure 28
Sweetener deliveries to the USA beverage industry
as a percentage of total sweetener deliveries
Source: Sugar and Sweeteners Outlook (SSS-M-293), USDA Economic Research Service, 2013
Figure 26
Caloric intake of sweeteners by country
Source: USDA-ERS, Conadesuca, OECD, Credit Suisse Research
800
600
700
500
400
300
200
100
B
a
n
g
la
d
e
s
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ia
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x
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o
Calories from HFCS Calories from sugar
0
Figure 29
Diet soda consumption (as a % of total soda
consumption) vs. relative educational standard
Source: Euromonitor, Nielsen XAOC, Credit Suisse estimates
Figure 31
Diet soda consumption relative to the % of the population
with a bachelor’s degree or more
Source: Nielsen, http://www.census.gov/people/
SUGAR_24 SUGAR_25
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Public policy initiatives
With few exceptions, regulators and health officials around the world have
done little to address the impact of excess sugar consumption. We believe
higher taxation on “sugary” food and drinks would be the best option to
reduce sugar intake and help fund the fast-growing healthcare costs
associated with diabetes type II and obesity. However, lobbying in this area
has been fierce and has watered down or stopped major initiatives.
Against mounting evidence of the negative impact
of sugar and HFCS on obesity, diabetes type II,
metabolic syndrome or rising levels of uric acid
and cardiovascular disease, the reaction of regula-
tors around the world has been limited to incre-
mental taxes (mostly on soft drinks), stricter
guidelines on labeling, bans on distribution of a
few sugary products in public buildings and
schools, limits on the size of drink packages, small
changes in the official dietary guidelines and some
educational advertisement.
Several issues have constrained, and will con-
tinue to limit the response of regulators, health offi-
cials and governments. Yet time is ticking by and
the related healthcare costs are rising fast. While
there is not one single action that will reverse the
global epidemic of obesity, diabetes, etc., we
believe that public opinion on this issue is gaining
momentum. This will force regulators to do some-
thing and drive companies, or at least the largest
ones, to self-regulate and take concrete actions to
reduce the amount of added sugar in their products.
Regulatory attempts: A limited response
Why have regulators been so slow in reacting?
Three main motives emerge: (1) The “culprits” span
across several businesses, and many of which are
impractical to regulate, (2) there has been consis-
tently strong lobbying from the affected parties, and
(3) there is the lack of a proper legal framework (at
least in the USA) to confront such a complex issue.
1. There is no “one-size-fits-all” solution to the
problems related to dietary caloric increase and the
excess sugar we are now consuming. Calories,
including those derived from sugar, are present
across a wide array of products. Sugar exists not
only in soft drinks and fruit juices, but also in sauces
(even the most talented Italian chefs add a little
sugar to a tomato sauce), bread, pasta, rice, ham
and so forth.
The clearest “targets” in controlling dietary sugar
consumption have been the beverage companies.
We would argue that these companies have played
the most prominent role in increasing the amount of
sugar present in our diets through recent history.
Combined with our body’s inability to recognize liquid
calories and feel satiated, this has led to some of the
negative health outcomes we mentioned before.
2. Lobbying in this area has been quite fierce. At
the top, stands the “global sugar lobby,” often
regarded as the most powerful commodity lobby
behind that dedicated to preserving the interests
of the oil industry. With governments promoting
artificially high prices for sugar, and implementing
quotas to protect the labor bases devoted to sugar
beet and sugar cane (equivalent to government
subsidies), there is little interest to reduce sugar
consumption among those in charge of agricul-
tural policies.
While health officials would justifiably support
measures aimed at reducing the availability of
sugar, one could argue that the votes available to
politicians supporting sugar-reducing actions are
fewer and far between than those supporting the
farmers. As a side note, the general consensus has P
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[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
also been that any attempt to regulate the bever-
age industry in the USA would be more likely
directed at the corn industry (responsible for manu-
facturing HFCS). That industry simply has less
leverage than the sugar industry, and its farmers
can always substitute their crop into biofuel produc-
tion. These interests, in turn, are reinforced and
supported by another powerful lobby, the beverage
and food manufacturers lobby.
As an example, when New York State consid-
ered introducing a tax on sugary beverages in
2009, the American Beverage Association (the
largest US trade organization for soft-drink bottlers)
formed a “New Yorkers Against Unfair Taxes” coali-
tion, spending a not insubstantial USD 9.4 million
on a widespread campaign to halt the proposal.
Another prominent group formed by the manufac-
turers and food retailers has operated under the
name of “Americans Against Food Taxes.” It would
be reasonable to assume similar groups will emerge
on other occasions where taxes or other financially
burdensome measures are being considered.
3. It is unclear what agency or government body
should or could take the lead on this, particularly in
the USA. In the case of tobacco, the US Congress
passed an extraordinary measure empowering the
FDA to deal with the issue. However, it is a conten-
tious debate whether the federal government would
be entitled to act in a similar manner over sugar.
Local and state authorities, on the other hand, can
act faster, as they have the power to introduce laws
to protect public health, safety and welfare. In
Europe and Asia, individual countries continue to
drive change in this area rather than collective bod-
ies like the European Community. France and Hun-
gary have been most active on this front.
Health-based legislation versus the power
of lobbying
Economists generally agree that government inter-
vention, including taxation, is justified when the
market fails to provide the optimum amount of a
good for society’s well-being. In the USA, 33 states
have either enacted taxes (albeit very small, 5% on
average) on soft drinks, or put legislation into place
stating that soft drinks are non-exempt from state
taxes unlike other basic foodstuffs. The UK shows
a similar picture, whereby the tax on soft drinks
(and all other non-essential, “luxury” foods for that
matter) is value-added tax (VAT); not a direct tax in
itself, but one that implicitly treats soft drinks as
non-essential. We expect some states in the USA
to become more active in this area. After Mayor
Bloomberg’s recent attempt to limit the size of the
offerings of sugary sodas, California is considering
pushing through a penny-per-ounce excise tax on
soft drinks. As we mentioned, a recent poll shows
that 68% of the people interviewed would be in
favor of this.
On a more national level, the FDA is currently not
considering any proposals to control or regulate
sugar consumption. According to the legal experts
we consulted, even if the FDA decided to tackle the
issue tomorrow and analyze whether excess sugar
consumption is toxic, it would take at least three
years to draft a proposal, followed by a further two
years of debate. A less-than-swift response to a
growing concern, by anyone’s standard.
Over in Europe, the French government appears
to be the most advanced in taking action. Just over
a year ago, it imposed a tax of EUR 0.02 on sugary
drinks and artificially flavored drinks; close to 5% of
the overall value. The potency of the lobbies could
be seen here once again: a very small tax in itself,
which was then also applied to zero calorie soft
drinks flavored with artificial sweeteners. The tax
has had the desired effect, with the carbonated
soft drink market dropping by 5% in volume last
year (according to market researcher Canadean).
However, this could be attributed more to psycho-
logical effects than financial ones. Fundamentally, it
is bad PR to have your industry taxed for health
reasons. Aside from that, there are proposals to
increase this tax to 20% by next year. Whether this
legislation is again diluted, or materializes at all, is
difficult to know. We should note that France is the
largest sugar-beet producer in Europe.
Hungary and Ireland, going one step further,
have taken a wider stance and are already impos-
ing taxes on perceived “unhealthy” foods in gen-
eral. Just this May in Ireland, a further 10% tax on
soft drinks was proposed and supported by a wide
majority of the public. In the UK, 61 organizations,
including the Academy of Medical Royal Colleges,
are advocating a GBp 7 tax per can of soft drink
(around 20% of the retail price) to be included in
the spring budget.
Yet, contrary to this prevailing trend, Denmark
reduced a long standing tax on soft drinks of EUR
0.22 per liter to half that in July, with plans to scrap
it completely by early 2014. The reasoning behind
this change, however, has been driven more by
financial considerations as opposed to social-health
concerns. Danes often cross into neighboring
countries in order to import cheaper soda from bor-
der shops; affecting both state taxes and local retail
shops. Essentially, the closer the consumer was to
the German border, the less soft drinks they pur-
chased domestically.
This shows that a cohesive action is much
needed. So where is the European Union on all
this? The European Union is in some ways behind
the curve and, by our accounts, focusing solely on
two issues: labeling and artificial sweeteners. With
regard to labeling, all companies will be required to
clearly show the amount of calories, fat, salt and
sugar on their product labels by the end of 2014.
At the same time, the European Union has focused
on artificial sweeteners and Aspartame in particular.
Nothing on sugar. The legislation in the works, if
implemented, will limit the ADI (average daily
intake) level for Aspartame to 40 mg per kg of body
weight (a can of diet coke contains 180 mg). The
French authorities, however, have suggested they
would prefer somewhere in the region of 5–10 mg
as a maximum recommended level (two cans for a
person weighing 70 kg or 154 pounds).
In Asia and Australia, the debate is only just on
the horizon. Given the rising levels of obesity, par-
ticularly in China and the Middle East, we believe
the status quo could soon be confronted. Again we
expect different countries to implement different
measures to reduce sugar consumption, looking
west to assess the pros and cons of all the avail-
able options.
Focusing taxation on where it matters most
While taxation may be not enough to address obe-
sity concerns and may vary from country to country,
or from state to state, we argue that this would be
the most effective way of dealing with the related
concerns. Effectiveness here is measured simply
as the overall reduction in consumption of added
sugar. Taxing at the right level should theoretically
achieve this, and academic studies have shown it
to work. After all, price is an important determinant
of food choices and diet. Theoretically, all foods P
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[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
containing added sugar should be targeted in an
attempt to reduce daily intake; however, soft drinks
could effectively bear the brunt of any financial levy.
A neutral observer would argue that govern-
ments are simply “picking on” an easy target – the
beverage manufacturers. However, due to the poor
satiating properties of sugar in liquid form, it could
be argued that they are a major contributor – if not
the largest – to the current epidemic of obesity, dia-
betes and metabolic syndrome and, at the same
time, they are clearly easier to regulate and tax
from a social perspective. Soft drinks are not
essential to our diet as are bread, pasta or rice.
Water is always a viable alternative. In addition, the
beverage industry accounts for one third of all
added sugars in our diet.
So, if the sole objective is to reduce the con-
sumption of full-calorie soft drinks, one does not
need to reinvent the wheel. Tobacco and alcohol
provide relevant test cases, and unequivocally show
that, in both cases, taxation has been able to affect
consumption on the downside.
In the case of tobacco, several studies sponsored
by the WHO would suggest that a 10% increase in
taxes leads to a 4% drop in consumption in high-
income countries and 8% in low-income countries.
The pattern of events in South Africa provides fur-
ther confirmation of this (see Figure 32). During the
1990s, tobacco tax rates rose 250%, eventually
accounting for 50% of the retail price. For every
10% increase in the price of cigarettes, consump-
tion fell by 5% to 7%. There are now 26 countries in
the world where tobacco taxes represent more than
75% of the retail price, a factor clearly correlating
with the overall reduction in smoking globally. Simi-
larly, in the case of alcohol, governments and policy
makers have utilized taxes as a way to reduce con-
sumption and, in parallel to this, fund education to
help cover the related healthcare costs.
How high?
Studies by professors Brownell and Frieden, Myt-
ton and Rayner have attempted to ascertain the
price elasticity of several foods and beverages.
Specifically for soft drinks, the estimate has been
that a roughly 10% increase in prices would bring
about an 8%–10% reduction in consumption.
While we would agree there is a relationship, we
do not believe it is one that is perfectly linear.
Empirical evidence would suggest that, at low lev-
els of taxation, consumption is not affected on a
one-to-one basis, but significantly less. Con-
versely, the higher the price increase, the higher
the multiplier. Empirical evidence supports these
findings. There have been few randomized con-
trolled trials (RCTs). In Ireland, a 10% increase in
the price of soft drinks in the 1980s led to an 11%
decrease in consumption. In this case, the price
increase affected all soft drinks.
So what would be the effect of introducing a 1%
tax per ounce on soft drinks? This would be equiva-
60 %
50 %
40 %
30 %
20 %
10 %
US population Non-hisp. white Non-hisp. black Mexican
Higher income Medium income
0 %
Low income
Figure 34
Percentage of obese population by income and race – USA
Source: CDC/NCHS, National Health and Nutrition Survey, Credit Suisse analysis
Figure 35
Annual global soda consumption versus GDP per capita
Source: Euromonitor, Nielsen XAOC, Credit Suisse estimates
120
80
60
100
Annual soda consumption per capita (liters) 160
140
40
20
0 10000 20000 40000 50000 30000 60000 70000
0
GDP per capita (USD)
Mexico Argentina
USA
United Arab Emirates
R
2
0.3453
Chile
Belgium
Norway
Switzerland
Spain
Brazil
India
China
Malaysia
Russia
Japan
Hong Kong, China
Singapore
France
Italy
Poland
Peru
Slovakia
Bulgaria
South Africa
Colombia
Venezuela
Czech Republic
Finland
Turkey
Hungary
Greece
Romania
South Korea Ukraine
Thailand
Philippines
Morocco
Egypt
Portugal
Indonesia
Denmark
Sweden
Netherlands
Germany
Canada
Israel
United Kingdom
Australia
Ireland
New Zealand
Saudi Arabia
Austria
lent, in reality, to increasing the price of a can by
20%. We see only positive implications if health is
the main consideration.
One could expect it to reduce consumption by an
equivalent amount or at least induce a switch from
high-sugar-content soft drinks to lower- or zero-
sugar soft drinks. The effect could be even higher
than the theoretical 20% (one-to-one price elastic-
ity), as most larger beverage manufacturers have a
lower- or zero-sugar content offering with a similar
flavor. We would also expect the impact to be higher
on soft drinks than juices, based simply on the per-
ception that juices are “healthier” and a substitute
(albeit a poor one) for eating the real fruit.
The tax is likely to be a regressive one (e.g.
affecting more people at lower income levels).
However, this might be positive not negative, as the
poorer and less educated seem to be affected the
most on relative basis by obesity and metabolic
syndrome. Figure 34 shows that, within the lower
income segment, 26% of non-hispanic blacks and
43% of hispanics in the USA are obese versus a
20% national average. So a hefty excise tax is
likely to impact more those segments of the popu-
lation where the problem is more acute.
A tax of this nature should provide soft-drink and
juice companies with an additional incentive to
adapt their product lines and lower the sugar con-
tent. It should be noted, that many of them are
already working toward this.
A tax would help local, state and federal govern-
ments raise much needed funds to address the
related health issues and devote additional funding
for better education and research on the topic. Esti-
mates based on the current level of consumption,
and a price elasticity of one, suggest that a 1% tax
per ounce would be able to generate USD 15 billion
in tax revenues in the USA, or USD 1 billion if we
were to consider New York State alone. A few aca-
demic studies have gone further in trying to approx-
imate the actual impact on weight reduction. Con-
servative estimates point to a 2 lb. per year per
person decline, assuming that the consumer substi-
tutes the 15% reduction in beverage intake (aver-
age of 10%–20%) with other more solid foods. It is
by no means enormous, but still healthier than see-
ing incremental weight gain in the population
As is always the case with very public issues,
critics and lobbyists have come up with a myriad of
reasons why this would be prejudicial. Their main
argument revolves around the claim that the tax
would be regressive, would not solve the obesity
crisis, and that it points the finger at one sector
alone. We have already addressed the issue of its
regressive nature. Critics are correct in the sense
that this would not entirely solve the epidemic of
obesity and diabetes, etc., but few are likely to dis-
agree that it is certainly a start, and a step in the
right direction. Reducing the growth of the obese
population while funding some of the healthcare
costs associated with these problems is an objec-
tive that is difficult to oppose in any regard.
2500 Cigarette consumption
(millions of packs)
Tobacco excise tax as
a % of retail price
2000
1500
500
1000
1980 1985 1990 1995 2000 2006
Consumption Excise tax rate
45%
40%
35%
30%
25%
20%
15%
5%
10%
0% 0
Figure 32
Cigarette consumption and excise tax rate in South Africa,
1980–2006
Source: WHO report on the Global Tobacco Epidemic, 2008
Figure 33
US price elasticity estimates, by food and beverage
category, 1938–2007
Source: American Journal Public Health, Canadean
Note*: Values were calculated based on the 160 studies reviewed. Absolute values of elasticity estimates are
reported. The price elasticity of demand measures the percentage change in purchased quantity or demand
with a 1% change in price.
Food and beverage
category
Absolute value of mean
price elasticity estimate
(95 % CI)
Range No. of
estimates
Food away from home 0.81 (0.56, 1.07) 0.23–1.76 13
Soft drinks 0.79 (0.33, 1.24) 0.13–3.18 14
Juice 0.76 (0.55, 0.98) 0.33–1.77 14
Beef 0.75 (0.67, 0.83) 0.29–1.42 51
Pork 0.72 (0.66, 0.78) 0.17–1.23 49
Fruit 0.70 (0.41, 0.98) 0.16–3.02 20
Poultry 0.68 (0.44, 0.92) 0.16–2.72 23
Dairy 0.65 (0.46, 0.84) 0.19–1.16 13
Cereals 0.60 (0.43, 0.77) 0.07–1.67 24
Milk 0.59 (0.40, 0.79) 0.02–1.68 26
Vegetables 0.58 (0.44, 0.71) 0.21–1.11 20
Fish 0.50 (0.30, 0.69) 0.05–1.41 18
Fats/oils 0.48 (0.29, 0.66) 0.14–1.00 13
Cheese 0.44 (0.25, 0.63) 0.01–1.95 20
Sweets/sugars 0.34 (0.14, 0.53) 0.05–1.00 13
Eggs 0.27 (0.08, 0.45) 0.06–1.28 14
SUGAR_30 SUGAR_31
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Lastly, we wish to focus our analysis on the impact
on corporates: we can divide this into five groups:
(1) food and beverage companies, (2) the sugar
industry (sugar cane, beet sugar and HFCS), (3)
HIS (artificial sweeteners), (4) natural sweeteners,
and (5) the healthcare Industry,
We believe that the implications of our analysis
for the beverage industry and the natural-sweet-
ener industry will drive the outlook for the other four
sectors:
1. We expect companies in the beverage industry
(mostly soft drinks) to react to the growing public
concern and the threat of taxes on sugary drinks by
moving as fast as they can to self-regulate and
change tack. We will look at self-regulation in
detail, but the most attractive option to achieve this
will be to develop soft drinks that leverage natural
sweeteners to reduce the overall caloric content or
replace artificial sweeteners. If properly managed,
we think these changes should have a neutral
effect on the beverage industry, be negative for
artificial sweeteners and very positive for natural
sweeteners. The key issue is taste. Natural sweet-
eners need to be able to deliver a taste profile that
is as pleasant as the full sugary drink or the one
that uses artificial sweetener – something that the
manufacturers have found very difficult over the
past few decades.
2. We think the impact on companies in the food
industry should be minimal as they do not suffer
Corporates:
Self-regulation
and opportunities
Several sectors will be impacted by the increased focus on the health
effects of excess sugar consumption: food and beverage companies,
sugar producers, manufacturers of artificial and natural sweeteners
and healthcare companies. We expect sugar consumption to decline
with an impact on sugar prices. The beverage industry has the tools
and marketing experience to embrace change and provide new
offerings to better match consumer wishes. Natural sweeteners
should be the main beneficiaries.
from the same negative image as the beverage
industry, they are more difficult to regulate and
they are less affected by the biomedical issues
linked to sugary beverages. We expect the industry
to gradually substitute sugar or HFCS with natural
sweeteners.
3. The sugar industry is likely to be negatively
affected, but it will take some time. As the aware-
ness of the medical risk tied to excess consumption
of added sugars increases worldwide, and as the
availability of natural sweeteners increases, we
expect sugar consumption to grow below the
growth rate of the global population. We should see
this happen first in developed countries (2–5 years)
and then gradually extend to developing countries
(10 years). If just the beverage industry in the USA
were to stop using sugar or HFCS and use natural
or artificial sweeteners, demand for sugar would
drop by 30%.
4. The healthcare industry should benefit from
increased awareness, which in turn should lead to
a reduction in the growth rate for obesity, diabetes
type II and metabolic syndrome. We are still far
away from this in many regards, so that, in the
short term, this clearly means increased costs for
the healthcare system. However, if sugar con-
sumption is curtailed, pharma and biotech compa-
nies closely tied to the treatment of diabetes type II
should – on a longer-term basis – see a reduction
in the potential number of addressable patients. P
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SUGAR_32
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Beverages: Self-regulation
Let us go into more detail and focus first on the
beverage industry. We believe that few countries
will implement taxes on soft drinks at the level we
suggest. Some countries already have taxes on
soft drinks, but at lower levels (see Figure 36 for
Latin America). Mexico might be a game changer
in this area and become the first of the large soft-
drink consumer markets to impose a significant
excise tax on full-calorie soft drinks as part of the
new government’s budget later this year.
In our view, however, the most likely outcome is
that the overhanging threat of higher taxes and the
fast-growing public outcry over the purported con-
tribution of soft-drink manufacturers to the health
issues we mentioned will coerce the companies to
self-regulate.
So what are the major soft-drink and
food companies (with the focus clearly
more on the former) going to do in order
to self-regulate?
Understandably, the soft-drink companies have lit-
tle interest in reducing the overall consumption of
soft drinks, but at the same time they can ill afford
being seen by the public as responsible for a major
obesity or diabetes epidemic.
We believe seven actionable responses are
available to the manufacturers:
• Increase availability of the zero-calorie version in
every region and country.
• Promote the marketing of “diet” drinks more than
full-calorie drinks.
• Gradually reduce the calorie content of the full
calorie version (although previous attempts to
change traditional formulas, such as with “New
Coke” have been known to backfire).
• Improve and make more visible the labeling of
the sugar content of drinks; in some countries
there is still no obligation to do so.
• Replace sugar and artificial, intense sweeteners
with natural, low- or zero-calorie sweeteners.
• Expand portfolios to offer alternative drinks (fruit
juices, vitamin waters, energy drinks or simply
smaller sizes – as they have recently announced
with the new 25 cl “slimline” cans in the UK).
• Launch public initiatives and campaigns to foster
a healthier and more active way of life. In other
words, take an active role in promoting a healthier
lifestyle and educating people about diet choices.
Soft-drink companies are likely to continue lobbying
against taxation of soft drinks through special-pur-
pose and fully funded groups (e.g. Americans
Against Food Taxes), but will have to be careful to
not do so openly. The tone of the latest press
release from the Coca-Cola Company shows a
remarkable change – from ignoring the media link-
ing obesity and diabetes to soft-drink consumption
to taking steps to present Coca-Cola as being well
Figure 36
Taxes on soft drinks in Latin America
Source: Credit Suisse Equity Research, Fomento Economico Mexicano, S.A.B., Form 20-F 2007
2.0 %
4.0 %
6.0 %
2.0 %
0.0 %
Carbonated drinks YoY change in volume (12 week rolling) 6.0 %
4.0 %
8.0 %
Mar-10 Jul-10 Nov-10 Jul-11 Nov-11 Mar-11 Jul-12 Nov-12 Mar-12 Jul-13 Mar-13
Regular Diet
Figure 37
Volumes for both diet and regular carbonated drinks
products continue to decline
Source: Euromonitor, Nielsen XAOC, Credit Suisse estimates
aware of these issues and working to be part of the
solution. For companies with brands as strong as
Coca-Cola or Pepsi, the biggest risk to sales growth
and profitability is a negative public image.
Here soft-drink companies have a huge advan-
tage over tobacco and alcohol companies. Tobacco
manufacturers could not offer nicotine-free or
smoke-free cigarettes (only now, decades later, are
we seeing the emergence of electric cigarette
technology). Beer brewers experimented with zero-
alcohol beers, but with very little success. Guinness
launched 0% Kaliber in 1986 as an upmarket alter-
native to other alcohol-free lager brands, and it is
now generally the only such product widely avail-
able in most markets. Clearly, we are still quite
some distance away from a zero-alcohol wine or a
zero-alcohol whisky. With this in mind, soft-drink
companies have a real chance to take a proactive
approach at making the right changes and come
out on the winning side.
What can change and what is likely to
change?
If we evaluate the world as a whole, it becomes
clear there is ample scope to improve the current
situation, particularly in emerging markets, and
most notably in Mexico, by offering and proactively
marketing the “diet” version.
Is it just a coincidence that Mexico ranks No. 3
in per-capita-soda-consumption and No. 2 in global
obesity rates, and at the same time sugary soft
drinks representing 95% of total soft-drink con-
sumed nationally? We do not think so. In this area,
as we said before, showing causality is incremen-
tally problematic, but assuming that all factors are
Figure 38
Full-calorie versus diet carbonated-drink consumption –
by region
Source: Beverage-Digest, Canadean
coincidental is undoubtedly worse. For further proof
of the concept, it is interesting to note that, in Italy,
sugary soft drinks account for 73% of the total
soft-drink consumption, and the country itself ranks
No. 35 in per capita soda consumption and No. 25
globally in obesity rates. Is this just a coincidence?
Analyzing this relationship in more granular form,
we turn our attention to the USA, which is a coun-
try where soft drinks are fully available in every
state. We can see that the level of sugary versus
“diet” soft drinks varies across the country, with a
clear pattern emerging. Using census data for edu-
cation and average income, we note there is a
remarkable correlation between the penetration of
the diet version and the level of education and
income. In other words, the higher the income and
education level of the consumer, the higher the
penetration of the “healthier” version of cola. We
can conclude that better access to information may
be a focal point in “controlling” the situation.
Generalizing this hypothesis elsewhere, one
could assume similar interpretations as in the USA.
There is one caveat, however. The availability of the
diet version of any given cola may, traditionally, not
be as extensive as it is in the USA, which goes
some way to explain why emerging-market con-
sumption of “diet” cola only accounts for 5% of the
total, versus a considerably higher 28% in the
western world. Regional sugar lobbies may also
play a role in governmental support for one over the
other, as most colas will use the locally available
“sugars” to sweeten their beverages. Not surpris-
ingly, in Mexico, the sugar in the full-calorie coke is
derived from cane sugar (true for most of Latin
America), while, in the USA, the sugar is provided
by the corn industry in the form of HFCS.
0 1 2 3 4 5 6 7 8 9 10 11 12
Teaspoons of sugar per 340 ml/12.oz serving
Starbucks Frappuccino Vanilla
7-Up
Nestea Lemon Iced Tea
Full Throttle Energy Drink
Gatorade Orange
Snapple Diet Teas
Starbucks Low Calorie Iced Coffee Light
Red Bull Energy Drink
Fresh Orange Juice
Pepsi Classic
Coca Cola Classic
Mountain Dew
Fanta Orange
Figure 39
Sugar content of popular beverages – teaspoons per serving
Source: California Center for Public Health 2011 study, Credit Suisse Research
2012 Full calorie share
of consumption
Diet share of
consumption
Asia 96.9 % 3.1 %
Eastern Europe 96.7 % 3.3 %
Southern Africa 95.8 % 4.2 %
MENA 95.2 % 4.8 %
Latin America 93.0 % 7.0 %
Western Europe 75.5 % 24.5 %
North America 69.0 % 31.0 %
Australasia 64.7 % 35.3 %
Worldwide 85.9 % 14.1 %
VAT
rate
Excise rate Excise taxes
as % of sales
(estimated)
Mexico 16 %    
Guatemala 12 % 0.18 cents local currency per liter 2.9 %
Costa Rica 13 % 22.53 local currency per 250 ml 13.8 %
Nicaragua 15 % 9 % consumption, 1% gross income 9.4 %
Panama 0 % 5 % depending of cost of good,
10 % selective products
7.5 %
Argentina 17 % 8.7% if drink has less than 5 % lemon
or 10 % fruit juice
8.5 %
Colombia 16 %    
Brazil 18 % Average production 4.7 %,
average sales 10.8 %
10.8 %
Venezuela 21%    
SUGAR_34 SUGAR_35
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
2002 2012
Other (*), 2012, 22
Milk, 10
Beer, 11
Bottled water, 12
Tap water, 21
Soft drinks, 24
Soft drinks, 29
0 %
-480 bps
Other (*), 2002, 22
Milk, 11
Beer, 12
Bottled water, 8
Tap water, 17
100 %
Figure 40
Beverage product portfolios – corporates are expanding
their product portfolios
Source: Beverages Digest Factbook 2013, Credit Suisse Research
Tough times ahead for artificial sweeteners
A big debate has unfolded, particularly in the Euro-
pean community, on the use of artificial sweeten-
ers. The word “artificial” plays a key role here, and
the main focus of the examination has been Aspar-
tame. While there is no conclusive proof that
Aspartame is dangerous to people’s health, there
have been numerous, conflicting recommendations
as to the maximum recommended daily limit.
As we mentioned, in the USA, the FDA turned
down the use of Aspartame as a sweetener six
consecutive times, before finally approving it. The
European community had initially agreed to a rec-
ommended international standard of 40 mg per kg
of bodyweight, but French authorities have sug-
gested they would want this reduced further to a
maximum of 5–10 mg per kg of body weight.
There are only a few medical studies on this
topic, and ultimately no reliable conclusions. The
combination of a growing negative public opinion on
artificial sweeteners and new discoveries in the field
of natural sweeteners should lead to a gradual
decline in the use of Aspartame and other
artificial sweeteners. Companies like Tate and Lyle
that have been at the center of the sweeteners mar-
ket are moving fast to develop new products
in the area of natural sweeteners and to partner with
beverage and food companies to reduce the level of
sugar in their products without impacting the taste.
The “sweet spot”: Natural sweeteners
Soft-drink companies are working hard to introduce
natural non-caloric or low-calorie natural sweeten-
ers, into their product offerings. The main concern
so far, however, has been that natural sweeteners
simply do not taste the same as sugar, and in some
cases leave a bitter after-taste. Coke is trialing Ste-
via in Sprite in France and has recently launched a
new version of coke called “Coca Cola Life” in
Argentina that is sweetened with 50% sugar and
50% Stevia. Coca Cola Life has 50% less calories
than the full-calorie Coke version. The word “natu-
ral” is key in the development and adoption of a
new generation of sweeteners by the food and bev-
erage industry. Stevia derived from the Stevia plant
is already available; Nectresse derived from Monk
fruit is also now available both industrially and as
table sugar. Xylitol or “alcohol sugar,” which occurs
naturally in some fruit, vegetables, mushrooms and
cereals is used both in sport drinks and certain
foods. The latest natural sweetener is a new prod-
uct called Brazzein or Cweet which is derived from
an African plant, the Oubli (Pentadiplandra brazz-
eana). We expect more to come in the near future
as the race for a natural, non-caloric sweetener
(that is widely accepted by the public) is heating up.
Fruit juices and others
As mentioned, one of the responses of the soft-
drink industry to the growing public concern about
soft drinks has been to enlarge portfolios, expand-
ing into bottled water, fruit juices and sport drinks.
Water (both tap and bottled) has gained a signifi-
cant share of total consumers’ liquid intake, while
carbonated soft drinks have lost 480 basis points
over the last ten years.
We have largely omitted fruit juices from our
analysis here, but in the spirit of an exhaustive
study, we should draw attention to some key points.
As can be seen in Figure 39, natural fruit juices and
fruit juices derived from concentrate do not fare
much better than full-calorie sodas when looking at
this issue from a health perspective.
Yet there are certain discernible differences.
The body reacts differently to fruit juices than sug-
ary sodas, both in terms of physiology and the
“satiation effect” we mentioned earlier (which
works better with fruit juices). In addition, fruit
juices contain other nutrients/vitamins that might
be beneficial to our body. However, the impact of
too much juice consumption is not vastly different
than when too many cans of full-calorie soda are
ingested. Yet the outcry is far less than that of
sodas. Why?
First and foremost, fruit juices are perceived as
“natural” products, and there has undoubtedly been
a trend over the past decade to favor natural and
organic products in our diets. But make no mistake.
Our forefathers did not drink fruit juices (certainly
not in the quantity that we do) – they simply ate the
fruit. While eating the fruit may lead to ingesting
roughly the same amount of sugar, the body fully
“notices” the calorie intake when eating the fruit
and, as a result, substitutes these calories for other
food-derived calories, not simply adding to them.
Also, natural fruits are rich in vitamin C, antioxi-
dants, flavonols and other substances that combat
the metabolic effects of fructose. Some of these
benefits disappear in the “juice” version of the fruit.
As several fruit-juice brands are ultimately owned
by the large soda manufacturers, there is hope that
the same remedial actions we cited above will be
applied to fruit juices as well. While substituting the
“natural sugar” in fruit juices with natural non-caloric
sweeteners, such as Stevia or Monk Fruit may
sound “unnatural,” this would be consistent and
likely to happen, albeit at a much slower pace.
Beyond juices, it would be a little excessive to
list each and every commercial foodstuff containing
added sugar. Few are aware that, in a single serv-
ing of Prego’s tomato sauce, there are 10 grams of
sugar (almost three spoons in total). Although this
is not quite the level seen in fruit juices (where a
500 ml orange juice can contain over 50 grams of
sugar), it should nevertheless be considered incre-
mental. In due course, we would expect these
companies to gradually follow the lead of the soft-
drink manufacturers.
Figure 41
Artifcial sweeteners
Source: Prairie Moon Company
Figure 42
Global product launches including Sucralose as an
ingredient
Source: Mintel
3000
2500
2000
1500
1000
500
2008
+11%
2009
+21%
2010
+9%
2011
+6%
2012
+11%
0
Figure 43
Examples of natural sweeteners
Source: Credit Suisse Consumer Staples Research
Sweetener Sweetness
relative to
sugar
Manu-
facturer
Regulatory /
FDA categorisation
Acesulfame potassium 200 x Nutrinova FDA approved 1988
Alitame 2,000 x Pfizer FDA approval pending
Aspartame 160–200 x NutraSweet FDA approved 1981
Aspartame-
acesulfame-salt
350 x Twinsweet FDA approved
Cyclamate 30 x Abbott FDA banned 1969,
Pending re-approval
Dulcin 250 x Not applicable FDA banned 1950
Neohesperidine
dihydrochalcone
1,500 x Nutrafur FDA no classification
Neotame 8,000 x NutraSweet FDA approved 2002
P-4000 4,000 x Not applicable FDA banned 1950
Saccharin 300 x Multiple FDA approved 1958
Sucralose 600 x Tate & Lyle FDA approved 1998
Natural
Ingredient
Commercial
product
Sweetness Company Calories
Stevia Truvia 10–15 times
> sugar
Cargill 0
Monkfruit Nectresse/
Purefruit
150–300 times
> sugar
Tate and Lyle 0
Oubli Brazzein/
Csweet
1000 times
> sugar
Cargill and Natur
Research
0
Xylitol in corn
fibers, birch
wood
Xylitol 15–30 times
> sugar
24 companies
in China, Canada
and USA
40 %
< sugar
Oats Oatsweet same as sugar Oat Tech 15 %–20 %
< sugar
SUGAR_36 SUGAR_37
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
“….we’ve been developing new natural sweet-
eners and flavoring aimed at reducing calories
with no compromise on taste. We have some
promising projects that are currently going
through the FDA review process that once com-
mercialized could potentially alter the trajectory
of our cola business in a meaningful way.” Indra
Nooyi, PepsiCo CEO, 2013 earnings call]
Both Coca-Cola and PepsiCo are experimenting
with new sweeteners and have formed partnerships
with smaller companies specializing in this field.
Coca-Cola’s joint venture with Blue Circle to
develop a Stevia-based sweetener called Rebaudi-
oside X is another example of things to come.
Experts assume breakthroughs will filter through in
the next 3–5 years and a discreet substitution of
Aspartame or Acesulfame Potassium will take a
place initially in the “diet” sodas (consumers are
more willing to try something different provided it
ensures zero calories). More gradually, these
switches will take place as a way to reduce the
caloric content of the full-calorie drinks.
When that occurs, we expect big labels to heavily
highlight the reduced calorie content version of the
new drink, as Pepsi did with Pepsi Next, or more
recently Dr Pepper with its 10 calorie versions of
Sunkist, 7-Up and A&W root beer. As Figures 44
and 45 show, the limitation of many of these new,
low-calorie drinks is that the encouraging initial cus-
tomer response and uptake can soon be followed by
a steady decline in consumption. Patrons are ready
and willing to try new products, but soon fall back on
old favorites. Public awareness of the negative
health effects tied to sugar consumption and
improved taste profiles could change this trend.
Companies have now an added incentive to make a
major change in not just marketing, but also in their
overall product strategy.
Potentially positive: US managed care
Increasing prevalence of diabetes and other health
issues has put significant pressure on the US
health system, which today spends nearly USD
3 trillion annually on healthcare costs. Some num-
bers might help place this in a proper context.
Obesity alone accounts for 20% (or USD 190
billion) of US national health expenditures and dia-
betes and metabolic syndrome account for a similar
figure (though there might be some double-count-
ing). So 30%–40% of healthcare expenditures in
the USA go to help address issues that are closely
tied to the excess consumption of sugar. Diabetes
is the fastest growing: 15% of US adults or close
to 40 million are expected to be diabetic by 2020
compared to 12% now.
As we move forward, there is greater pressure
under the US healthcare reform to control the
unsustainable healthcare cost trend with a focus on
chronic conditions. Large employers, individuals,
state and federal governments have all looked to
Figure 44
Pepsi Next hits 8% of total Pepsi volumes, but falls
back to under 2% within a year
Source: Based on AC Nielsen data XAOC
Figure 45
Dr Pepper 10-calorie hits 7% of total Dr Pepper volumes,
but falls back to 3% in under a year
Source: Based on AC Nielsen data XAOC
7 %
8 %
9 %
5 %
6 %
4 %
3 %
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Dr Pepper 10 as % Dr P
7Up 10 as % 7Up total
A&W 10 as % A&W total
Percent of adult population 60 %
50 %
40 %
30 %
20 %
10 %
2
0
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7
2
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Diabetes Prediabetes Combined
Figure 46
Prevalence of diabetes and prediabetes in the US adult
population 2007–20
Source: UnitedHealth Group Modeling, 2010 (http://www.unitedhealthgroup.com/hrm/unh_workingpaper5.pdf)
managed care as a means of reducing costs. Con-
trolling and managing the growth in obesity and
diabetes are key elements of this effort. Similar
issues apply to the rest of the world. In most coun-
tries, the growing costs for the healthcare system
will be an added burden to public sector finances
and ultimately to the tax payer.
So what are managed-care companies doing to
help contain the costs to the system? Managed care
has developed plans that for the most part offer
health and wellness programs to individuals and cor-
porate clients. The key words here are “prevention”
and “proper treatment.” A large portion of the world
population is in a pre-diabetic stage: over 60 million
people in the USA and over 400 million globally.
Proper diagnostics and then intervention could
reduce the number of “new diabetics” drastically and
significantly reduce the costs to the healthcare sys-
tem. The same applies to a certain extent to people
that already have diabetes. In both cases, reduction
in the level of consumption of sugar would benefit
the affected individuals and the system. As we dis-
cussed, education, taxation, proper labeling and a
wider use of new natural sweeteners could help to
improve the current situation and reverse this trend.
Figure 47
Estimated savings opportunities for initiatives to address obesity, pre-diabetes,
diabetes in US adults, by public payers, 2011–20
Source: UnitedHealth Group Modeling, 2010 (http://www.unitedhealthgroup.com/hrm/unh_workingpaper5.pdf)
Expected net health care cost savings by payer,
2011–20 (in USD bn)
Federal State Total
public
% system
savings
Health
system
People without diabetes — lifestyle intervention
(recommended weight loss)
23 1 24 53 % 45
People with prediabetes — intensive lifestyle intervention
like the Diabetes Prevention Plan
61 3 64 61 % 105
People with diabetes — improved medication adherence
(Asheville & ten cities)
21 1 22 63% 34
People with diabetes — intensive lifestyle intervention
(Look Ahead)
53 2 55 62 % 88
All initiatives (net of interactions) 144 6 150 60 % 250
As costs have escalated, programs that can reduce
or bend the cost curve have become increasingly
important. The challenge is to demonstrate the
return on investment (ROI) from an employer’s per-
spective from investing in health and wellness pro-
grams. As health plans work further to collect and
synthesize data, we will have a clearer picture. If
results show positive ROIs, health and wellness
programs may become increasingly more impor-
tant. The healthcare reform may accelerate this
trend as more uninsured people gain access to
coverage, thus increasing healthcare costs.
More broadly, the focus on lower costs and
individual/employer engagement in healthcare is a
significant opportunity for managed care in the
longer term. If managed care is viewed as part of
the solution, we see an incremental business
opportunity (sharing the savings with government,
privates and corporations). However, given the
significant changes impacting health insurers in
2014 with healthcare reform, we think this par-
ticular theme is overshadowed by the uncertainty/
potential disruption of next year’s events and it is
therefore not necessarily priced into the managed-
care stocks.
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SUGAR_38
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
Potentially negative in the long term:
Biopharma and medical devices
On the product side of the healthcare industry,
there are many companies that have invested sig-
nificant resources in developing drugs to treat obe-
sity, as well as drugs to treat some of the complica-
tions from obesity, such as type II diabetes, high
cholesterol and high blood pressure. Five of the 20
most successful drugs of all time, in fact, are drugs
that target some of these common complications
(see Figure 48).
The development of drugs for treating obesity in
particular has been challenging. These drugs have
generally had a limited impact on weight loss or
have had significant side effects that overshad-
owed any efficacy that patients experienced. In
fact, many of the drugs that were previously
approved have since been withdrawn from the mar-
ket due to some of these safety concerns (Figure
49). While some newer agents have recently
entered the market and others are in late-stage
development, it remains to be seen if any of these
will be more successful commercially.
Diabetes mellitus, on the other hand, has been
an area of significant success for the biopharma
industry. These drugs have focused on lowering
blood sugar levels in patients with diabetes since
better sugar control has been shown to limit
some of the long-term complications of the dis-
ease, such as heart disease, kidney disease,
neurological problems and visual disorders. There
have been a number of different classes of drugs
developed for diabetes over the past several
decades, ranging from injectable products (such
as insulin and GLP-1 receptor agonists) to oral
medications (such as biguanides and DPP-4
inhibitors, Figure 50). Many of these classes
include drugs that have generated multi-billion
dollars in sales.
Beyond drugs, healthcare companies have also
invested in other innovations to attempt to respond
to the obesity epidemic and the dramatic rise in
the number of patients with diabetes. Some have
focused on developing inhalers or automated
pumps that allow for potentially easier or more
convenient dispensing of insulin. Other companies
have focused on more invasive approaches such
as the development of adjustable gastric bands
that wrap around part of the stomach and attempt
to slow (and ultimately reduce) the amount of food
a person consumes during meals.
While we do not anticipate a rapid reduction in
the rates of obesity or type II diabetes, if changes
in sugar consumption were to materially impact
the incidence or prevalence of these conditions,
the addressable market for these companies
might not be as large as projected. The compa-
nies that have focused significant research and
development expenses on these areas may not
see the return on their investment that they initially
expected.
Figure 50
Diabetes classes of drugs developed for diabetes
Source: Company data, Credit Suisse analysis
Figure 48
Leading obesity medications 2006–10
Source: Company data, Credit Suisse analysis
Medications Company Year approved Current status
Fenfluramine Warner-Lambert 1973 Withdrawn in USA, EU
Dexfenfluramine Warner-Lambert 1996 Withdrawn in USA, EU
Phentermine VarioUSA 1959 Marketed in USA,
withdrawn in EU
Meridia/Reductil Abbott 1997 Withdrawn in USA, EU
Xenical Roche 1998 Marketed in USA, EU
alli GSK 2007 Marketed in USA, EU
Accomplia/Zimulti Sanofi Aventis 2006 Withdrawn in USA, EU
Qsymia VivUSA 2012 Marketed in USA
Belviq Arena 2012 Marketed in USA
Contrave Orexigen
In clinical development Empatic Orexigen
liraglutide 3 mg Novo Nordisk
Figure 49
Summary of approval dates
Source: Company data, Credit Suisse analysis
Brand name Therapeutic category Peak year Peak sales (USD bn)
Lipitor Cholesterol 2006 13.7
Plavix Anticoagulant 2011 9.9
Humira Autoimmune 2012 9.3
Remicade Autoimmune 2012 8.2
Seretide Respiratory 2011 8.1
Enbrel Autoimmune 2012 8.0
Abilify Central nervous system 2012 7.6
Rituxan Oncology 2012 7.2
Crestor Cholesterol 2011 6.6
Lantus Diabetes 2012 6.4
Herceptin Oncology 2012 6.3
Losec Antiulcerants 2000 6.3
Avastin Oncology 2010 6.2
Diovan High blood pressure 2010 6.1
Seroquel Central nervous system 2011 5.8
Singulair Respiratory 2011 5.5
Zocor Cholesterol 2002 5.4
Nexium Antiulcerants 2007 5.2
Zyprexa Central nervous system 2010 5.0
Diabetes class Administration Examples (brand name)
Insulin Injectable Lantus, Humalog, Novolog
GLP-1 Analog Injectable Byetta, Victoza, Bydureon
Sulfonylurea Oral Glucotrol, Amaryl
Biguanide Oral Glucophage
Thiazolidinediones Oral Actos, Avandia
DPP-4 Inhibitor Oral Januvia, Onglyza, Tradjenta
SGLT2 Inhibitor Oral Invokana
TITLE AUTHORS DATE
Sucrose, High-Fructose Corn Syrup, and
Fructose, Their Metabolism and Potential
Health Effects: What Do We Really Know?
James M. Rippe and Theodore J.
Angelopolous
April 24,
2013
Energy and Fructose From Beverages Sweet-
ened With Sugar or High-Fructose Corn
Syrup Pose a Health Risk for Some People
George A. Bray April 24,
2013
Dietary fructose consumption among US chil-
dren and adults: the Third National Health
and Nutrition Examination Survey
Vos MB, Kimmons JE, Gillespie C,
Welsh J, Blanck HM
2008
Fructose: It’s “Alcohol Without the Buzz” Robert H. Lustig Department of
Pediatrics and the Philip R. Lee
Institute for Health Policy Studies,
University of California, San
Francisco, CA
April 24,
2013
The Extraordinary Science of Addictive Junk
Food
Michael Moss February
20, 3013
Fructose: Is It Bad For Our Health?
A commentary prepared for a joint ILSI North
America/USDA Workshop: State-of-the-
Science on Dietary Sweeteners Containing
Fructose
George A. Bray, MD Boyd Professor
LSU System
March 2008
The Relationship of Sugar to Population-Level
Diabetes Prevalence: An Econometric Analysis
of Repeated Cross-Sectional Data
Sanja Basu, Paula Yoffe, Nancy
Hills, Robert H. Lustig
February
27, 2013
Fructose, Sucrose, and High Fructose Corn
Syrup:” Modern Scientifc Findings and Health
Implications
James M. Rippe, Penny M. Kris
Etherton
February 8,
2013
Taxing unhealthy food and drinks to improve
health
An increasing number of countries are
introducing taxes on unhealthy food and drinks,
but will they improve health?
Oliver Mytton, academic clinical
fellow
Dushy Clarke, researcher, Mike
Rayner, director
May 15,
2012
Associations between state-level soda taxes
and adolescent body mass index
LM Powell, J. Chriqui, FJ Chaloupka 2009
Point-of-purchase price and education
intervention to reduce consumption of sugary
soft drinks
JP Block, A Chandra, KD McManus,
WC Willett
2010
Estimating the potential of taxes on sugar
sweetened beverages to reduce consumption
and generate revenue
T Andreyeva, FJ Chaloypka, KD
Brownell
2011
Global Status Report on Alcohol World Health Organization
Department of Mental Health and
Substance Abuse
2004
Effects of beverage alcohol price and tax levels
on drinking: a meta-analysis of 1003 estimates
from 112 studies
Alexander C. Wagenaar, Matthew J.
Salois, Kelli A. Komro
2009
The Medical Device Excise Tax – Over before
It Begins?
Daniel B. Kramer, M.D., Aaron S.
Kesselheim, M.D., J.D., M.P.H.
May 9,
2013
Limiting “Sugary Drinks” to Reduce Obesity –
Who Decides?
Wendy K. Mariner, J.D., M.P.H.,
George J. Annas, J.D., M.P.H.
April 3,
2013
Improving Obesity Prevention at the Local
Level – Emerging Opportunities
Sara N. Belch, Ph.D.
Lainie Rutkow, J.D., Ph.D., M.P.H
May 9,
2013
Portion Sizes and Beyond – Government’s
Legal Authority to Regulate Food-Industry
Practices
Jennifer L. Pomeranz, J.D., M.P.H.,
Kelly D. Brownell, Ph.D,
October 11,
2012
What Do Government Agencies Consider in
the Debate Over Added Sugars?
David M. Klurfeld April 25,
2013
Intake of added sugars and selected nutrients
in the United States
BP Marriott, L Oslo, L Hadden,
P Connor, National Health and
Nutrition Examination Survey
(NHANES)
2010
Effect of fructose on body weight in controlled
feeding trials: a systematic review and meta-
analysis
JL Sievenpiper, RJ de Souza, A
Mirrahimi, ME YU, AJ Carleton, J
Beyene, L Chiavaroli, M Di Buono,
Al Jenkins, LA Leiter
2012
The effects of fructose intake on serum uric
acid vary among controlled dietary trials
DD Wang, JL Sievenpiper, RJ de
Souza, L Chiavaroli, V Ha, AI Cozma
A Mirrahimi, Me Yu, AJ Carleton,
M Di Buono
2012
The Toxic Truth about Sugar RH Lustig, LA Schmidt, CD Brindis 2012
Food price and diet and health outcomes: 20
years of the CARDIA Study
KJ Duffey, P. Gordon-Larsen, JM
Shikany, D Guilkey, DR Jacobs, BM
Popkin Jr.
2010
Could targeted food taxes improve health? Oliver Mytton, Alastair Gray, Mike
Rayner, Harry Rutter
5/10/2013
Cigarette smoking by socio-economic group,
sex, and age: effects of price income and
publicity
J Townsend, P Roderick, J Cooper 1994
TITLE AUTHORS DATE
Economic aspects of tobacco use and taxation
policy
C. Godfrey, A. Maynard 1988
Institute of Alcohol Studies and tax Institute of Alcohol Studies 2003
The Public Health and Economic Benefts of
Taxing Sugar-Sweetened Beverages
Kelly D. Brownell, Ph.D., Thomas
Farley, M.D., M.P.H., Walter C.
Willett, Md.D., Dr.P.H, Barry M.
Popkin, Ph.D,, Frank J. Chaloupka,
Ph.D, Joseph W. Thompson, M.D.,
M.P.H, David S. Ludwig, M.D., Ph.D
2009
Overweight and Obesity Statistics Weight-control Information Network
An information service of the
National Institute of Diabetes and
Digestive and Kidney Diseases
(NIDDK)
5/10/2013
Ounces of Prevention – The Public Policy
Case for Taxes on Sugared Beverages
Kelly D. Brownell, Ph.D.
Thomas R. Frieden, M.D., M.P.H.
4/30/2009
Consumption of high-fructose corn syrup in
beverages may play a role in the epidemic
of obesity
GA Bray, SJ Nielsen, BM Popkin 2004
Obesity and Cardiovascular disease risk:
research update
KJ Melanson, KJ McInnis, JM Rippe
G Blackburn, PF Wilson
2001
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Council on Science and Public Health
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2010
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sucrose consumption on circulating glucose,
insulin, leptin, and ghrelin and on appetite in
normal-weight women
KJ Melanson, L Zukley, J Lowndes,
V Nguyen, TJ Angelopoulos, JM
Rippe
2007
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The medical-care cost burden of obesity D Thompson, AM Wolf 2001
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come.
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related to insulin resistance in adolescents.
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Dieuzeide
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A casual role for uric acid in fructose-induced
metabolic syndrome
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The roles of dopamine and related compounds
in reward-seeking behavior across animal phyla
AB Barron, E Sovik, JL Cornish 2010
Potential role of sugar (fructose) in the
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metabolic syndrome, diabetes, kidney disease
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Baker
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on fructose content
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sucrose in the ability to cause fatty liver
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equine laminitis
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2001
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LEARN diets for change in weight and related
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SUGAR_40 SUGAR_41
[email protected] Khalil Barrage 01/31/14 07:13:52 PM Invus Group LLC
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October 2011
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January 2011
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January 2012
Opportunities in an
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